Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0203X | Pediatric Critical Care Doctor | 036-103836 | IL |
Y | 2080P0203X | Pediatric Critical Care Doctor | 51779 | WI |
NPI | 1073623260 |
---|---|
Provider Name | Martin K. Wakeham |
First Address | Milwaukee, WI 53226-4874 |
Second Address | Milwaukee, WI 53226-4874 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 06/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036103836 | (05) | IL |
1073623260 | (05) | WI |
G61325 | (02) | IL |