Provider Demographics
NPI:1043015837
Name:WOLVERINE HEALTHCARE LLC
Entity type:Organization
Organization Name:WOLVERINE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SLABAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC, BSN, RN
Authorized Official - Phone:617-517-6340
Mailing Address - Street 1:82 WENDELL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-7066
Mailing Address - Country:US
Mailing Address - Phone:617-517-6340
Mailing Address - Fax:423-301-6604
Practice Address - Street 1:82 WENDELL AVE STE 100
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-7066
Practice Address - Country:US
Practice Address - Phone:617-517-6340
Practice Address - Fax:423-301-6604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-15
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty