Provider Demographics
NPI:1164193322
Name:WETTENGEL, GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WETTENGEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WOODCLIFF CIR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4288
Mailing Address - Country:US
Mailing Address - Phone:402-630-6316
Mailing Address - Fax:
Practice Address - Street 1:1630 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3391
Practice Address - Country:US
Practice Address - Phone:402-630-6316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant