Basic Information
| Provider Information | |||||||||
| NPI: | 1053869099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANYO | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | DENDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | BLAIRSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157178096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434068 | ||||||||
| Practice Location | |||||||||
| Address1: | 16515 POTTSVILLE PIKE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HAMBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 195268182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846603139 | ||||||||
| FaxNumber: | 4846603373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2016 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT025588 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1019541330001 | 05 | PA | MEDICAID |