Provider Demographics
NPI:1376869966
Name:MACON, WENDY (PTA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 OLSEN BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-3053
Mailing Address - Country:US
Mailing Address - Phone:806-467-8181
Mailing Address - Fax:
Practice Address - Street 1:3701 OLSEN BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-3053
Practice Address - Country:US
Practice Address - Phone:806-467-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2072209225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1518070366OtherNPI
TX752754865OtherTAX ID
TX00519VMedicare PIN