Provider Demographics
NPI:1700930302
Name:CHISHOLM, WENDY (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:702-838-8265
Mailing Address - Fax:702-804-3788
Practice Address - Street 1:888 S RANCHO DR
Practice Address - Street 2:URGENT CARE
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3810
Practice Address - Country:US
Practice Address - Phone:702-877-8600
Practice Address - Fax:702-258-6152
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1184363A00000X, 363A00000X
WAPA10005120363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1700930302Medicaid
NVP00915410OtherRAILROAD MEDICARE
NVP00915410OtherRAILROAD MEDICARE
NV1700930302Medicaid
NVCU149ZMedicare PIN
NVCU149YMedicare PIN
WA14088UOtherREGENCE PIN
Q75957Medicare UPIN
NVCU149ZMedicare PIN