Provider Demographics
NPI:1750643557
Name:WANNAMAKER, MEGAN (DO)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WANNAMAKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 KINGSLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657-1409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2691
Practice Address - Country:US
Practice Address - Phone:973-754-4399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09551900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine