Provider Demographics
NPI:1629288089
Name:LATACK, WAYNE ARTHUR (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:ARTHUR
Last Name:LATACK
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 1:301 FISHER ST
Mailing Address - Street 2:KEESLER AFB
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2508
Mailing Address - Country:US
Mailing Address - Phone:228-376-3372
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:KEESLER AFB
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-376-3372
Practice Address - Fax:228-376-0125
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21859208M00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS21859OtherMEDICAL LICENSURE