Provider Demographics
NPI:1558748103
Name:WERTZ, BARRY THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:THOMAS
Last Name:WERTZ
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 1:7601 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4133
Mailing Address - Country:US
Mailing Address - Phone:260-436-8686
Mailing Address - Fax:260-436-8585
Practice Address - Street 1:7601 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4133
Practice Address - Country:US
Practice Address - Phone:260-436-8686
Practice Address - Fax:260-436-8585
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001953A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant