Provider Demographics
NPI:1346232311
Name:WHARTON, WENDELL S JR (PA)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:S
Last Name:WHARTON
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 AGNES AVENUE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262
Mailing Address - Country:US
Mailing Address - Phone:310-608-0477
Mailing Address - Fax:310-608-2657
Practice Address - Street 1:4204 AGNES AVENUE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262
Practice Address - Country:US
Practice Address - Phone:310-608-0477
Practice Address - Fax:310-608-2657
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 10547363A00000X, 363AM0700X
CAPA10547363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP56642Medicare UPIN
CAOPA105470Medicare ID - Type Unspecified