Provider Demographics
NPI:1154395937
Name:WANNER, WILLIAM R (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:WANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3128
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-3128
Mailing Address - Country:US
Mailing Address - Phone:712-239-4702
Mailing Address - Fax:712-224-5898
Practice Address - Street 1:5885 SUNNYBROOK DR
Practice Address - Street 2:SUITE L-200
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4203
Practice Address - Country:US
Practice Address - Phone:712-239-4702
Practice Address - Fax:712-224-5898
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-22826207RC0000X
SD1716207RC0000X
NE16952207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0192401Medicaid
IA41352Medicare PIN
IA41022Medicare PIN
IA41371Medicare PIN
IA42832Medicare PIN
IA41246Medicare PIN
IA41296Medicare PIN
IA41362Medicare PIN
IA41380Medicare PIN
A01944Medicare UPIN
IA41389Medicare PIN
NE269456Medicare PIN
IA0192401Medicaid
IA41307Medicare PIN
IA41278Medicare PIN
IA41287Medicare PIN
IA41316Medicare PIN
IA41325Medicare PIN
IA41343Medicare PIN
IA41269Medicare UPIN