Provider Demographics
NPI:1104374396
Name:WEGENHOFT, JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WEGENHOFT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LAUREN
Other - Last Name:TRAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 S AUSTIN RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77434-3202
Mailing Address - Country:US
Mailing Address - Phone:979-234-2551
Mailing Address - Fax:979-234-5994
Practice Address - Street 1:610 S AUSTIN RD
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:TX
Practice Address - Zip Code:77434-3202
Practice Address - Country:US
Practice Address - Phone:979-234-2551
Practice Address - Fax:979-234-5994
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1137272OtherNCCPA