Provider Demographics
NPI:1245341692
Name:BERTRAM, WENDY L (APRN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:L
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 N. RUSSELL LONG BLVD
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79016-0001
Mailing Address - Country:US
Mailing Address - Phone:806-651-3287
Mailing Address - Fax:806-651-3289
Practice Address - Street 1:2620 N. RUSSELL LONG BLVD
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79016-0001
Practice Address - Country:US
Practice Address - Phone:806-651-3287
Practice Address - Fax:806-651-3289
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX241305363LF0000X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1245341692OtherTX APN # 118004 AND TX NURSING LICENSE 241305
TX202973802Medicaid
TX8L23644Medicare UPIN
NM62575376Medicaid
OK200275400 AMedicaid