Provider Demographics
NPI:1629506753
Name:WIECZORKOWSKI, MICHAEL (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WIECZORKOWSKI
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CONCORD PLAZA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6991
Mailing Address - Country:US
Mailing Address - Phone:210-804-5911
Mailing Address - Fax:
Practice Address - Street 1:400 CONCORD PLAZA DR STE 300
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6991
Practice Address - Country:US
Practice Address - Phone:210-804-5911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT57812255A2300X
363AM0700X, 390200000X
TXPA17404363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program