1346856846 NPI number — MRS. CAITLYN CLARE WAGENBACH PA-C

Table of content: MRS. CAITLYN CLARE WAGENBACH PA-C (NPI 1346856846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346856846 NPI number — MRS. CAITLYN CLARE WAGENBACH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGENBACH
Provider First Name:
CAITLYN
Provider Middle Name:
CLARE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HONAN
Provider Other First Name:
CAITLYN
Provider Other Middle Name:
CLARE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346856846
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62794-9248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-528-7541
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4616 N PROSPECT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61616-6460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-528-7541
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2020

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com