Provider Demographics
NPI:1184784530
Name:WENCL, RUDOLPH RICHARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:RUDOLPH
Middle Name:RICHARD
Last Name:WENCL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:719-538-2900
Mailing Address - Fax:719-538-2990
Practice Address - Street 1:600 S 21ST ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3762
Practice Address - Country:US
Practice Address - Phone:719-522-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0001485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000204150Medicaid