Basic Information
| Provider Information | |||||||||
| NPI: | 1366410961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASSNER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DIRK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058205227 | ||||||||
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| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059548720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD2006-0010 | NM | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 80509568 | 05 | NM | MEDICAID | 10024478 | 01 | NM | LOVELACE | OTHER | 2607463 | 01 | UHC | OTHER | NM009X29 | 01 | NM | BCBS NM | OTHER | QMYPR0070898 | 01 | MOLINA HEALTHCARE | OTHER | 202005441 | 01 | PRESBYTERIAN HEALTH PLAN | OTHER |