Provider Demographics
NPI:1366410961
Name:WASSNER, JOHN DIRK (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DIRK
Last Name:WASSNER
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 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-820-5227
Mailing Address - Fax:
Practice Address - Street 1:465 SAINT MICHAELS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7670
Practice Address - Country:US
Practice Address - Phone:505-954-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0010208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80509568Medicaid
NM10024478OtherLOVELACE
2607463OtherUHC
NMNM009X29OtherBCBS NM
QMYPR0070898OtherMOLINA HEALTHCARE
202005441OtherPRESBYTERIAN HEALTH PLAN
NMNM009X29OtherBCBS NM
QMYPR0070898OtherMOLINA HEALTHCARE