Provider Demographics
NPI:1396050720
Name:TOOMER, DWAYNE M
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:M
Last Name:TOOMER
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 1:718 ADDISON ST APT E
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1353
Mailing Address - Country:US
Mailing Address - Phone:215-294-0817
Mailing Address - Fax:
Practice Address - Street 1:718 ADDISON ST APT E
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1353
Practice Address - Country:US
Practice Address - Phone:215-294-0817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403026363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health