Provider Demographics
NPI:1245608975
Name:FRU, WENCESLOUS (PA-C)
Entity Type:Individual
Prefix:
First Name:WENCESLOUS
Middle Name:
Last Name:FRU
Suffix:
Gender:M
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 1:22301 W ALSOP RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-5023
Mailing Address - Country:US
Mailing Address - Phone:907-538-2308
Mailing Address - Fax:907-864-8452
Practice Address - Street 1:3300 PROVIDENCE DR
Practice Address - Street 2:SUITE B314
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4690
Practice Address - Country:US
Practice Address - Phone:907-212-3420
Practice Address - Fax:907-212-3429
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK114514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant