Provider Demographics
NPI:1669597613
Name:ROSS, WANDA SAWYER (MD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:SAWYER
Last Name:ROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:152 BURNETTS WAY
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8166
Mailing Address - Country:US
Mailing Address - Phone:757-539-6217
Mailing Address - Fax:757-934-8535
Practice Address - Street 1:152 BURNETTS WAY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8166
Practice Address - Country:US
Practice Address - Phone:757-539-6217
Practice Address - Fax:757-934-8535
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036331208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6738290Medicaid
VAG74278Medicare UPIN