Provider Demographics
NPI:1295733467
Name:SUMNER, WENDELL WESTON (DO)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:WESTON
Last Name:SUMNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:10110 SPAIN RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1965
Mailing Address - Country:US
Mailing Address - Phone:505-294-5065
Mailing Address - Fax:505-298-2731
Practice Address - Street 1:10110 SPAIN RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1965
Practice Address - Country:US
Practice Address - Phone:505-294-5065
Practice Address - Fax:505-298-2731
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-569-71208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45245Medicaid