Provider Demographics
NPI:1861258865
Name:TESS-WANAT, IAN (DC)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:TESS-WANAT
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 1:331 OAK MANOR DR STE 101
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5553
Mailing Address - Country:US
Mailing Address - Phone:410-766-4878
Mailing Address - Fax:410-766-6619
Practice Address - Street 1:331 OAK MANOR DR STE 101
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5553
Practice Address - Country:US
Practice Address - Phone:410-766-4878
Practice Address - Fax:410-766-6619
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor