Provider Demographics
NPI:1326072281
Name:MISSELBECK, WAYNE ANTON (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ANTON
Last Name:MISSELBECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 ATKINS BAY LN
Mailing Address - Street 2:
Mailing Address - City:NORTH HERO
Mailing Address - State:VT
Mailing Address - Zip Code:05474-9757
Mailing Address - Country:US
Mailing Address - Phone:802-372-3449
Mailing Address - Fax:
Practice Address - Street 1:36 S MAIN ST
Practice Address - Street 2:GIFFORD MEDICAL CENTER EMERGENCY DEPARTMENT
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1370
Practice Address - Country:US
Practice Address - Phone:802-728-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-0007390207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80009231Medicaid
NYE01066279Medicaid
VT0009231Medicaid
VTB85562Medicare UPIN
NH80009231Medicaid