Provider Demographics
NPI:1497325393
Name:WANNAH, STEPHEN LOBASKY JR (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LOBASKY
Last Name:WANNAH
Suffix:JR
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 1:450 CHEW ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18102-3434
Mailing Address - Country:US
Mailing Address - Phone:610-776-4888
Mailing Address - Fax:
Practice Address - Street 1:450 CHEW ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102-3434
Practice Address - Country:US
Practice Address - Phone:610-776-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT224247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine