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Mary Katherine Wanstrom

Nurse Practitioner

Physician Assistants & Advanced Practice Nursing Providers

801 W. 34th Street, Suite 102, Austin, TX 78705

PECOS Enrollment

This provider is enrolled in PECOS as MARY WANSTROM.

Based on the most recent information from CMS, provider Mary Katherine Wanstrom is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.

Part B
Medicare Part B
Enrolled
HHA
Home Health Agency
Enrolled
DME
Durable Medical Equipment
Enrolled
PMD
Power Mobility Device
Enrolled

CMS last updated its PECOS records 5 days ago.

Profile Details

Provider ID
1417068370
Provider Type
Individual
Full Name
Wanstrom, Mary Katherine
Credential
FNP

Gender
Female
Sole Proprietor
No
Enumeration Date
8/31/2006
Last Updated
10/2/2018

Contact Information

Practice Location

801 W. 34th Street, Suite 102, Austin, TX 78705

(512) 371-9260

(512) 371-9550

Mailing Location

1201 W 49th St, Austin, TX 78756-3102

(512) 374-0203

Unlisted Fax

Provider Taxonomies

Code	Description	License
Code 363LF0000X Primary	Description Nurse Practitioner Physician Assistants & Advanced Practice Nursing Providers	License 565264 Texas

Provider Identifiers

ID	Description	Issuer
ID 8N9688	Description Other	Issuer BCBS TX INDIVID NO Texas
ID 173322201	Description Medicaid	Issuer Unlisted Texas
ID 9381771	Description Other	Issuer PCHS INDIV NO Texas

Mary Katherine Wanstrom

PECOS Enrollment

Profile Details

Contact Information

Practice Location

Mailing Location

Provider Taxonomies

Code

Description

License

Code

Description

License

Provider Identifiers

ID

Description

Issuer

ID

Description

Issuer

ID

Description

Issuer

ID

Description

Issuer

Clymer, Brynn

Bode, Sara

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Bonifacio, Erika Ongcangco

Targac Cortes, Stephanie

Perez, Eric Brandon

Gutierrez, Jaclyn Rene

Hauser, Gina

Mumm, Hawna

Russo, Amy Gauck