Provider Demographics
NPI:1194964254
Name:WACKER, PAIGE ANN (C HT)
Entity type:Individual
Prefix:MRS
First Name:PAIGE
Middle Name:ANN
Last Name:WACKER
Suffix:
Gender:F
Credentials:C HT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4631
Mailing Address - Country:US
Mailing Address - Phone:405-564-4766
Mailing Address - Fax:405-533-4343
Practice Address - Street 1:820 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4631
Practice Address - Country:US
Practice Address - Phone:405-564-4766
Practice Address - Fax:405-533-4343
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM204-214174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist