Provider Demographics
NPI:1619959236
Name:WASHENBERGER, WAYNE L (PAC)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:L
Last Name:WASHENBERGER
Suffix:
Gender:M
Credentials:PAC
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 1474
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1474
Mailing Address - Country:US
Mailing Address - Phone:605-226-2663
Mailing Address - Fax:605-226-0095
Practice Address - Street 1:701 8TH AVE NW STE A
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-1865
Practice Address - Country:US
Practice Address - Phone:605-226-2663
Practice Address - Fax:605-226-2663
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6823642Medicaid
SD1108470001Medicare NSC
ND712269Medicare PIN
SDP00348670Medicare PIN
P58087Medicare UPIN
SD101172Medicare PIN