Provider Demographics
NPI:1811261837
Name:ELIZABETH J WANNER, MD., PA
Entity type:Organization
Organization Name:ELIZABETH J WANNER, MD., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:281-351-1411
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:77375-4554
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:77375-4554
Practice Address - Country:US
Practice Address - Phone:281-351-1411
Practice Address - Fax:281-351-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty