Provider Demographics
NPI:1922004969
Name:WANNER, ELIZABETH J
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:WANNER
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 1:1101 ALMA ST
Mailing Address - Street 2:STE 102
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-4559
Mailing Address - Country:US
Mailing Address - Phone:281-351-1411
Mailing Address - Fax:281-351-0240
Practice Address - Street 1:1101 ALMA ST
Practice Address - Street 2:STE 102
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4559
Practice Address - Country:US
Practice Address - Phone:281-351-1411
Practice Address - Fax:281-351-0240
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111660001Medicaid
TX00T16PMedicare ID - Type Unspecified
TXF00687Medicare UPIN