Provider Demographics
NPI:1760546261
Name:WOLF, BRITTANY (PA-C)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:
Other - Last Name:AULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4600 MEMORIAL DR
Mailing Address - Street 2:STE. 120
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5368
Mailing Address - Country:US
Mailing Address - Phone:618-233-2220
Mailing Address - Fax:618-233-2555
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-233-2220
Practice Address - Fax:618-233-2555
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002914363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL546390Medicare ID - Type Unspecified
ILQ76060Medicare UPIN
ILIL3521022Medicare PIN