Basic Information
Provider Information | |||||||||
NPI: | 1528131711 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WANSKI | ||||||||
FirstName: | ZDZISLAUS | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1150 STATE HWY 248 SUITE 102 | ||||||||
Address2: |   | ||||||||
City: | BRANSON | ||||||||
State: | MO | ||||||||
PostalCode: | 65616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4173488990 | ||||||||
FaxNumber: | 4173488090 | ||||||||
Practice Location | |||||||||
Address1: | 1150 STATE HWY 248 SUITE 102 | ||||||||
Address2: |   | ||||||||
City: | BRANSON | ||||||||
State: | MO | ||||||||
PostalCode: | 65616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4173488990 | ||||||||
FaxNumber: | 4173488090 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2006 | ||||||||
LastUpdateDate: | 03/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | G36872 | CA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 2016030291 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | GR0083400 | 05 | CA |   | MEDICAID |