Provider Demographics
NPI:1376596312
Name:WANSA, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:WANSA
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:PO BOX 28247
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-8247
Mailing Address - Country:US
Mailing Address - Phone:480-967-6500
Mailing Address - Fax:480-967-6540
Practice Address - Street 1:250 PROSPECT PL
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1943
Practice Address - Country:US
Practice Address - Phone:619-522-3722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0080374207P00000X
CAG50191207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259748900Medicaid
FL35771AMedicare PIN