Provider Demographics
NPI:1831186303
Name:WOLKWITZ, JONATHAN (PA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WOLKWITZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:
Practice Address - Street 1:116 E. 2ND
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:NM
Practice Address - Zip Code:88230
Practice Address - Country:US
Practice Address - Phone:575-734-5817
Practice Address - Fax:575-734-6550
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96-PA22207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79336213Medicaid
NMP56920Medicare UPIN
NM79336213Medicaid