Provider Demographics
NPI:1376579540
Name:BULOW, WENDY A (PA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:A
Last Name:BULOW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004
Mailing Address - Country:US
Mailing Address - Phone:719-543-8718
Mailing Address - Fax:719-543-5340
Practice Address - Street 1:110 E ROUTT
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:719-543-5340
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1675363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85478075Medicaid