Provider Demographics
NPI:1639714645
Name:VAN BLARCOM, WAYNE EDWARD
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:EDWARD
Last Name:VAN BLARCOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 TATTENHAM COR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-1553
Mailing Address - Country:US
Mailing Address - Phone:713-858-2660
Mailing Address - Fax:
Practice Address - Street 1:4601 TATTENHAM COR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-1553
Practice Address - Country:US
Practice Address - Phone:713-858-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide