Provider Demographics
NPI:1568619682
Name:WENNERSTEN, ADAM M (PA-C)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:M
Last Name:WENNERSTEN
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 1:2222 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3709
Mailing Address - Country:US
Mailing Address - Phone:715-392-1955
Mailing Address - Fax:715-392-1935
Practice Address - Street 1:2222 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3709
Practice Address - Country:US
Practice Address - Phone:715-392-1955
Practice Address - Fax:715-392-1935
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11324363A00000X
WI2366-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant