Provider Demographics
NPI:1669480232
Name:WENNEKER, WENDELL WARREN (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:WARREN
Last Name:WENNEKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 VILLA LN
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6417
Mailing Address - Country:US
Mailing Address - Phone:707-226-2031
Mailing Address - Fax:707-252-1087
Practice Address - Street 1:3443 VILLA LN
Practice Address - Street 2:SUITE 3
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6417
Practice Address - Country:US
Practice Address - Phone:707-226-2031
Practice Address - Fax:707-252-1087
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37197208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G371970OtherBLUE SHIELD
CA00G371970Medicaid
CA00G371970Medicare PIN
A89636Medicare UPIN