Provider Demographics
NPI:1558566208
Name:WANNER, DAVID L (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:WANNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 PENNSYLVANIA AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-6413
Mailing Address - Country:US
Mailing Address - Phone:641-684-8448
Mailing Address - Fax:641-684-4055
Practice Address - Street 1:1005 PENNSYLVANIA AVE
Practice Address - Street 2:STE 202
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-6413
Practice Address - Country:US
Practice Address - Phone:641-684-8448
Practice Address - Fax:641-684-4055
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000801213E00000X
IAT00801213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0249003Medicaid
IA12920Medicare PIN