Provider Demographics
NPI:1316615594
Name:WAKER, MICHAEL JEFFREY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEFFREY
Last Name:WAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3683 HERMOSA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1146
Mailing Address - Country:US
Mailing Address - Phone:937-321-6005
Mailing Address - Fax:
Practice Address - Street 1:3683 HERMOSA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45416-1146
Practice Address - Country:US
Practice Address - Phone:937-321-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No347C00000XTransportation ServicesPrivate Vehicle