Provider Demographics
NPI:1316907975
Name:WANN, LEE S (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:S
Last Name:WANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:601 N 99 ST
Mailing Address - Street 2:STE 201
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-778-7790
Mailing Address - Fax:414-778-7646
Practice Address - Street 1:601 N 99TH ST
Practice Address - Street 2:STE 201
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4339
Practice Address - Country:US
Practice Address - Phone:414-778-7790
Practice Address - Fax:414-778-7646
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2013-03-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI22145207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30263800Medicaid
B57458Medicare UPIN
WI30263800Medicaid
WI023650008Medicare Oscar/Certification