Provider Demographics
NPI:1407966773
Name:CHRISTENSON, WAYNE A (DO)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:A
Last Name:CHRISTENSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2550 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-8695
Practice Address - Country:US
Practice Address - Phone:616-252-5600
Practice Address - Fax:616-252-5660
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4435857Medicaid
MIH51827Medicare UPIN
MI4435857Medicaid