Provider Demographics
NPI:1053796524
Name:PAYNE, DAMIEN
Entity type:Individual
Prefix:
First Name:DAMIEN
Middle Name:
Last Name:PAYNE
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 1:1087 WESTPORT DR APT 155
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2481
Mailing Address - Country:US
Mailing Address - Phone:414-208-0605
Mailing Address - Fax:262-364-2336
Practice Address - Street 1:1087 WESTPORT DR APT 155
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2481
Practice Address - Country:US
Practice Address - Phone:414-208-0605
Practice Address - Fax:262-364-2336
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100043804343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100043804Medicaid