Provider Demographics
NPI:1609173236
Name:WENDT, MICHAEL DARREN (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DARREN
Last Name:WENDT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33836-0878
Mailing Address - Country:US
Mailing Address - Phone:689-698-3720
Mailing Address - Fax:689-698-3720
Practice Address - Street 1:6545 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-6201
Practice Address - Country:US
Practice Address - Phone:904-861-1901
Practice Address - Fax:904-292-9265
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2023-08-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9112985363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant