Provider Demographics
NPI:1548229974
Name:FOOTE, WANDA E (CRNP)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:E
Last Name:FOOTE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:570-887-5050
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303483-1363L00000X
PASP004968C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02377948Medicaid
PACC9269OtherRR MEDICARE
PAGU039830OtherMEDICARE GROUP
PAP00286820OtherRR MEDICARE PIN
NY02377948Medicaid
PAGU039830OtherMEDICARE GROUP