Provider Demographics
NPI:1508496217
Name:WENCKUS, KOLTEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KOLTEN
Middle Name:
Last Name:WENCKUS
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 1:2900 12TH AVE N STE 140W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-7507
Mailing Address - Country:US
Mailing Address - Phone:406-237-5050
Mailing Address - Fax:
Practice Address - Street 1:2900 12TH AVE N STE 140W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7507
Practice Address - Country:US
Practice Address - Phone:406-237-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT81226OtherLICENSE
MTMW5723449OtherDEA