Provider Demographics
NPI:1609147461
Name:WONNENBERG, LEONARD TRENT (PAC)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:TRENT
Last Name:WONNENBERG
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 1ST ST NE STE 1
Mailing Address - Street 2:
Mailing Address - City:WESSINGTON SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57382-2163
Mailing Address - Country:US
Mailing Address - Phone:605-539-9836
Mailing Address - Fax:605-539-9546
Practice Address - Street 1:1000 18TH ST SW
Practice Address - Street 2:STE 27
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-3486
Practice Address - Country:US
Practice Address - Phone:605-554-1015
Practice Address - Fax:605-554-1016
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant