Provider Demographics
NPI:1518527605
Name:WENZEL, REGAN DANIELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:REGAN
Middle Name:DANIELLE
Last Name:WENZEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:REGAN
Other - Middle Name:DANIELLE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:1505 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-1907
Practice Address - Country:US
Practice Address - Phone:254-933-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1K2760OtherPTAN
TX4197196-01Medicaid