Provider Demographics
NPI:1497392070
Name:WASS, BRIAN KIRK
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KIRK
Last Name:WASS
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-0099
Mailing Address - Country:US
Mailing Address - Phone:209-742-0854
Mailing Address - Fax:209-742-0996
Practice Address - Street 1:5362 LEMEE LN
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9556
Practice Address - Country:US
Practice Address - Phone:209-966-2000
Practice Address - Fax:209-742-0996
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator