Provider Demographics
NPI:1154416501
Name:WARDEN, WANDA JEAN (PA-C)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:JEAN
Last Name:WARDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SUKI
Other - Middle Name:
Other - Last Name:WARDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:216-479-5541
Mailing Address - Fax:216-479-5554
Practice Address - Street 1:12301 SNOW ROAD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44130
Practice Address - Country:US
Practice Address - Phone:216-621-5600
Practice Address - Fax:216-479-5554
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P05768Medicare UPIN
WAPA15301Medicare ID - Type Unspecified