Provider Demographics
NPI:1477645968
Name:WENZLER, EVAN M (PT)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:M
Last Name:WENZLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1474
Mailing Address - Country:US
Mailing Address - Phone:518-453-9088
Mailing Address - Fax:518-689-3895
Practice Address - Street 1:121 EVERETT RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1474
Practice Address - Country:US
Practice Address - Phone:518-453-9088
Practice Address - Fax:518-689-3895
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030217-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY650021313OtherRR MEDICARE
CA0209359OtherSTATE OF WASHINGTON
NYA400058200Medicare PIN
CA0209359OtherSTATE OF WASHINGTON