Basic Information
| Provider Information | |||||||||
| NPI: | 1720030224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEGMANN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 902 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604578578 | ||||||||
| FaxNumber: | 3604574841 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604578578 | ||||||||
| FaxNumber: | 3604574841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00010877 | WA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8166704 | 05 | WA | MEDICAID |