Provider Demographics
NPI:1801263611
Name:WENTZ, KRISTEN KAY (PA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KAY
Last Name:WENTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:KAY
Other - Last Name:RUTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 S CEDAR CREST BLVD
Practice Address - Street 2:STE 110
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6224
Practice Address - Country:US
Practice Address - Phone:610-435-1003
Practice Address - Fax:610-317-3443
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057766363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical