Provider Demographics
NPI:1942967856
Name:WANKA, CHRISTOPHER MARK
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MARK
Last Name:WANKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23408
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-0530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 HARRY S TRUMAN DR N
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5477
Practice Address - Country:US
Practice Address - Phone:240-677-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC08975363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant