Provider Demographics
NPI:1467640524
Name:WENZEL, GRACE M (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:M
Last Name:WENZEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HOSPITAL AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1463
Mailing Address - Country:US
Mailing Address - Phone:814-375-3722
Mailing Address - Fax:814-375-3086
Practice Address - Street 1:145 HOSPITAL AVE STE 113
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801
Practice Address - Country:US
Practice Address - Phone:814-375-3722
Practice Address - Fax:814-375-3086
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30487207RC0000X
PAMD467098207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA808302OtherPTAN
PA103629311Medicaid