Provider Demographics
NPI:1619178274
Name:STOUTENGER, WAYNE A (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:A
Last Name:STOUTENGER
Suffix:
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 1:105 JENNIE DR
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-4001
Mailing Address - Country:US
Mailing Address - Phone:757-817-4667
Mailing Address - Fax:800-655-5268
Practice Address - Street 1:105 JENNIE DR
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-4001
Practice Address - Country:US
Practice Address - Phone:757-817-4667
Practice Address - Fax:800-655-5268
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAA102018OtherPTAN
VA0101050796OtherVA LICENSE
1619178274OtherNPI
VA0101050796OtherVA LICENSE
VA0101050796OtherVA LICENSE