Doctor Name: | DUSTIN WATTENBERGER |
NPI Number: | 1003231432 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | 3008537 |
Business Practice Address: | 1100 Richmond Rd Irvine, KY - 403367231 |
Business Phone Number: | 6067237706 |
Business Fax Number: | 6067269410 |
Mailing Address: | Po Box 636493, CINCINNATI |
State: | OH |
Postal Code: | 452636493 |
Phone Number: | 5139815130 |
Fax Number: | 5139815015 |
NPI Enumeration Date: | 02/21/2014 |
NPI Last Update Date: | 06/09/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | 3008537 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | KY |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |