Provider Demographics
NPI:1962647305
Name:DILLON, WENDY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:ANN
Last Name:DILLON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:ANN
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5523
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2435 W BELVEDERE AVE
Practice Address - Street 2:SUITE 42
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5224
Practice Address - Country:US
Practice Address - Phone:410-601-5523
Practice Address - Fax:410-601-8946
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03840363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS567Medicare PIN