Provider Demographics
NPI:1689807612
Name:BULLOCK, WENDELL BART (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:BART
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:BART
Other - Middle Name:
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:104 BURNEY DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-6621
Mailing Address - Country:US
Mailing Address - Phone:601-987-8200
Mailing Address - Fax:601-987-8211
Practice Address - Street 1:104 BURNEY DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6621
Practice Address - Country:US
Practice Address - Phone:601-987-8200
Practice Address - Fax:601-987-8211
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03856719Medicaid