Provider Demographics
NPI:1497736789
Name:WAHLERT, WILLIAM JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JACOB
Last Name:WAHLERT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 EUBANK BLVD NE
Mailing Address - Street 2:STE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3591
Mailing Address - Country:US
Mailing Address - Phone:505-298-8020
Mailing Address - Fax:505-237-8803
Practice Address - Street 1:3825 EUBANK BLD NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3591
Practice Address - Country:US
Practice Address - Phone:505-298-8020
Practice Address - Fax:505-292-5006
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM88PA17363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R58593Medicare UPIN