Provider Demographics
NPI:1053097139
Name:WANNER, BLAIR K
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:K
Last Name:WANNER
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 1:412 W RENO AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6247
Mailing Address - Country:US
Mailing Address - Phone:701-223-3781
Mailing Address - Fax:
Practice Address - Street 1:519 LANSING LN
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6563
Practice Address - Country:US
Practice Address - Phone:701-223-5217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care