Provider Demographics
NPI:1609833755
Name:WENNINGER, JEROME JOSEPH JR (PA-C MPAS)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:JOSEPH
Last Name:WENNINGER
Suffix:JR
Gender:M
Credentials:PA-C MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 S HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8708
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:
Practice Address - Street 1:7220 S HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8708
Practice Address - Country:US
Practice Address - Phone:605-341-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
SD0975363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS109386Medicare PIN