Provider Demographics
NPI:1417717307
Name:WASIKE, INNOCENT
Entity Type:Individual
Prefix:
First Name:INNOCENT
Middle Name:
Last Name:WASIKE
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 1:1601 W MACARTHUR BLVD APT 20D
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-8218
Mailing Address - Country:US
Mailing Address - Phone:714-579-5392
Mailing Address - Fax:
Practice Address - Street 1:550 N FLOWER ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-2361
Practice Address - Country:US
Practice Address - Phone:714-647-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95242296163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine