Provider Demographics
NPI:1356402259
Name:WANYO, JOHN D (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:WANYO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LUZERNE
Mailing Address - State:PA
Mailing Address - Zip Code:18709-1210
Mailing Address - Country:US
Mailing Address - Phone:570-288-0629
Mailing Address - Fax:570-283-0367
Practice Address - Street 1:68 MAIN ST
Practice Address - Street 2:
Practice Address - City:LUZERNE
Practice Address - State:PA
Practice Address - Zip Code:18709-1210
Practice Address - Country:US
Practice Address - Phone:570-288-0629
Practice Address - Fax:570-283-0367
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002182L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007675810001Medicaid
PA093081OtherFIRST PRIORITY HEALTH
PAWA1626351OtherHIGHMARK BLUE SHIELD
PA0042660000OtherINDEPENDENCE BLUE CROSS
PA11583801OtherCAQH
PA350002549OtherPALMETTO GBA
PA093081OtherFIRST PRIORITY HEALTH
PAWA020645Medicare Oscar/Certification
PA11583801OtherCAQH