Provider Demographics
NPI:1982959391
Name:WASANO, TIMOTHY E
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:WASANO
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 1:2720 PLAZA DR
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2720 PLAZA DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4158
Practice Address - Country:US
Practice Address - Phone:715-847-2472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4881-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily