Provider Demographics
NPI:1710172325
Name:WENDT, DONALD WALTER (PA-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:WALTER
Last Name:WENDT
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 1:304 W HAY ST
Mailing Address - Street 2:STE 111
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6328
Mailing Address - Country:US
Mailing Address - Phone:217-875-8100
Mailing Address - Fax:217-872-5486
Practice Address - Street 1:304 W HAY ST
Practice Address - Street 2:STE 111
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6328
Practice Address - Country:US
Practice Address - Phone:217-875-8100
Practice Address - Fax:217-872-5486
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK45330Medicare PIN