Provider Demographics
NPI:1982137725
Name:WANNER, BRIAN (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WANNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:485 TOM HALL ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-2353
Mailing Address - Country:US
Mailing Address - Phone:740-566-4621
Mailing Address - Fax:740-566-4622
Practice Address - Street 1:1409 N. FANT STREET
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-375-7551
Practice Address - Fax:864-231-8073
Is Sole Proprietor?:No
Enumeration Date:2017-04-08
Last Update Date:2022-12-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC83813207ND0101X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery