Provider Demographics
NPI:1639360936
Name:WANWIG, JOHN DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DANIEL
Last Name:WANWIG
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 1:1901 SO UNION
Mailing Address - Street 2:STE A305 ALLENMORE MEDICAL CENTER
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405
Mailing Address - Country:US
Mailing Address - Phone:253-272-3031
Mailing Address - Fax:253-272-9449
Practice Address - Street 1:1901 SO UNION
Practice Address - Street 2:STE A305 ALLENMORE MEDICAL CENTER
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-272-3031
Practice Address - Fax:253-272-9449
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA125822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA21793OtherL & I
WA1047786Medicaid
WA7229OtherREGENCE
WA7229OtherREGENCE