Provider Demographics
NPI:1497101521
Name:WANTA, PAUL (RN)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:WANTA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BEAR MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:WENDELL DEPOT
Mailing Address - State:MA
Mailing Address - Zip Code:01380-9704
Mailing Address - Country:US
Mailing Address - Phone:978-544-2399
Mailing Address - Fax:
Practice Address - Street 1:17 BEAR MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:WENDELL DEPOT
Practice Address - State:MA
Practice Address - Zip Code:01380-9704
Practice Address - Country:US
Practice Address - Phone:978-544-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-07
Last Update Date:2016-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN147772163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse