Provider Demographics
NPI:1689834582
Name:GEBAUER, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GEBAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3287 BUNKER HILL RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NY
Mailing Address - Zip Code:14772-9786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 W 2ND ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-5207
Practice Address - Country:US
Practice Address - Phone:716-484-9113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167351164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse