Provider Demographics
NPI:1528044674
Name:WENNER, DAVID R (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:WENNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 VARTAN WAY STE 270
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-9720
Mailing Address - Country:US
Mailing Address - Phone:717-221-7890
Mailing Address - Fax:717-221-7891
Practice Address - Street 1:2300 VARTAN WAY STE 270
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-9720
Practice Address - Country:US
Practice Address - Phone:717-221-7890
Practice Address - Fax:717-221-7891
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005483L207QH0002X
PAOS005483-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10980830001Medicaid
PA524573Medicare ID - Type UnspecifiedPROVIDER NUMBER
PA10980830001Medicaid