Provider Demographics
NPI:1407627540
Name:WAYER, MARK ALAN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:WAYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9175 62ND ST S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016
Mailing Address - Country:US
Mailing Address - Phone:618-980-6393
Mailing Address - Fax:
Practice Address - Street 1:9175 62ND ST S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016
Practice Address - Country:US
Practice Address - Phone:618-980-6393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider