1316460579 NPI number — D'ANNE WENGENROTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316460579 NPI number — D'ANNE WENGENROTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENGENROTH
Provider First Name:
D'ANNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316460579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6700 WASHINGTON AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN PRAIRIE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55344-3405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-351-1529
Provider Business Mailing Address Fax Number:
952-285-3980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3155 SE MILITARY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78223-3824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-359-8433
Provider Business Practice Location Address Fax Number:
210-359-8429
Provider Enumeration Date:
07/19/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  80788 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 237600000X , with the licence number: 80788 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)