Provider Demographics
NPI:1710305230
Name:WAKEMAN, CAROLYN (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WAKEMAN
Suffix:
Gender:F
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:N6520 LUMBERJACK GUY RD
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5405
Mailing Address - Country:US
Mailing Address - Phone:715-284-9851
Mailing Address - Fax:715-284-5106
Practice Address - Street 1:N6520 LUMBERJACK GUY RD
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5405
Practice Address - Country:US
Practice Address - Phone:715-284-9851
Practice Address - Fax:715-284-5106
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68060207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine