Provider Demographics
NPI:1376532366
Name:WENZLAWSH, PAUL D (PA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:WENZLAWSH
Suffix:
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 1:3875 STOKES RD
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77418-9935
Mailing Address - Country:US
Mailing Address - Phone:979-865-4260
Mailing Address - Fax:
Practice Address - Street 1:600 N PARK ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-2610
Practice Address - Country:US
Practice Address - Phone:979-830-0530
Practice Address - Fax:979-830-0559
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXO4330363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D8353Medicare ID - Type Unspecified
TXQ50192Medicare UPIN