Provider Demographics
NPI:1689701815
Name:WAGENHEIM, ANDREW DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:DAVID
Last Name:WAGENHEIM
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 1:409 S 2ND ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 TECHNOLOGY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-9413
Practice Address - Country:US
Practice Address - Phone:717-791-2620
Practice Address - Fax:717-791-2621
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052910363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1954039OtherHIGHMARK BLUE SHIELD-WMG
PA1565334OtherGATEWAY-WMG
PA1954039OtherHIGHMARK BLUE SHIELD-WMG