Provider Demographics
NPI:1114498029
Name:WENNERSTROM, ELIZABETH ANN (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:WENNERSTROM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13460 N 94TH DR STE J1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4264
Mailing Address - Country:US
Mailing Address - Phone:623-876-8816
Mailing Address - Fax:623-298-0168
Practice Address - Street 1:13460 N 94TH DR STE J1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4264
Practice Address - Country:US
Practice Address - Phone:623-876-8816
Practice Address - Fax:623-298-0168
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7262363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ125100Medicaid