Provider Demographics
NPI:1598261455
Name:FUSSELL, WANDA LAI (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LAI
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-1405
Mailing Address - Country:US
Mailing Address - Phone:813-879-8045
Mailing Address - Fax:813-876-6504
Practice Address - Street 1:5105 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-1405
Practice Address - Country:US
Practice Address - Phone:813-879-8045
Practice Address - Fax:813-876-6504
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN66256207Y00000X
FLME163082207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology