Provider Demographics
NPI:1194359893
Name:WHEELER, JACOB KENNETH (PA-S)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:KENNETH
Last Name:WHEELER
Suffix:
Gender:M
Credentials:PA-S
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Other - Credentials:
Mailing Address - Street 1:6330 RIVERSIDE PLAZA LN NW STE 100
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-2682
Mailing Address - Country:US
Mailing Address - Phone:505-322-6687
Mailing Address - Fax:505-369-3406
Practice Address - Street 1:1755 TELSTAR DR FL 3
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1016
Practice Address - Country:US
Practice Address - Phone:505-322-6687
Practice Address - Fax:505-369-3406
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2025-08-29
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Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty