Provider Demographics
NPI:1013393370
Name:WROLSTAD, WAYNE
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:WROLSTAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 CHAPEL RD
Mailing Address - Street 2:UNIT C
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-3602
Mailing Address - Country:US
Mailing Address - Phone:610-766-7222
Mailing Address - Fax:610-766-7205
Practice Address - Street 1:7 MADONNA LN
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-2264
Practice Address - Country:US
Practice Address - Phone:610-804-0336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-09
Last Update Date:2015-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA28133601163WG0000X, 3747P1801X, 374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide