Healthcare Provider Details

I. General information

NPI: 1255683074
Provider Name (Legal Business Name): ARIELLE A. WOLF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DR
MATTOON IL
61938-9261
US

IV. Provider business mailing address

1005 HEALTH CENTER DR STE 201
MATTOON IL
61938-4693
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-2551
  • Fax: 217-258-2551
Mailing address:
  • Phone: 217-238-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004480
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: