Basic Information
| Provider Information | |||||||||
| NPI: | 1396717310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASEMILLER | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4120 W MEMORIAL RD | ||||||||
| Address2: | SUITE 218 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053022661 | ||||||||
| FaxNumber: | 4053022670 | ||||||||
| Practice Location | |||||||||
| Address1: | 4120 W MEMORIAL RD | ||||||||
| Address2: | SUITE 218 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053022661 | ||||||||
| FaxNumber: | 4053022670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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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 | 2084N0400X | 10843 | OK | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 100129160A | 05 | OK | MEDICAID |