Provider Demographics
NPI:1376114991
Name:WENCLAWIAK, MICHAEL JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:WENCLAWIAK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:762-235-2700
Practice Address - Fax:706-236-6437
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2024-03-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA10486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant