Provider Demographics
NPI:1922022524
Name:WASSERBAUER KINGSTON, NANCY (DO)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:WASSERBAUER KINGSTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:WASSERBAUER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1823
Mailing Address - Fax:440-617-0884
Practice Address - Street 1:19800 DETROIT RD
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-1816
Practice Address - Country:US
Practice Address - Phone:440-333-1107
Practice Address - Fax:440-333-1064
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008802207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2680915Medicaid
OHH304310Medicare PIN