Provider Demographics
NPI:1386631166
Name:WANAMAKER, JOHN RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAYMOND
Last Name:WANAMAKER
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 1:800 IRVING AVE
Mailing Address - Street 2:VA MEDICAL CENTER, SURGICAL SERVICES(112)
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2716
Mailing Address - Country:US
Mailing Address - Phone:315-425-4400
Mailing Address - Fax:315-425-2639
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:VA MEDICAL CENTER, SURGICAL SERVICES(112)
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-4400
Practice Address - Fax:315-425-2639
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189611207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01635029Medicaid
NY01635029Medicaid
F27565Medicare UPIN