Provider Demographics
NPI:1639709199
Name:WONNEBERGER, TOM (PA-C)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:WONNEBERGER
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 1:2149 WALNUT CREEK CT N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-5105
Mailing Address - Country:US
Mailing Address - Phone:904-651-6346
Mailing Address - Fax:
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112928363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant