Healthcare Provider Details

I. General information

NPI: 1619278074
Provider Name (Legal Business Name): WESLEY BRIAN ZWIEFEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 E MASON ST STE 4P57
SPRINGFIELD IL
62701-1034
US

IV. Provider business mailing address

619 E MASON ST STE 4P57
SPRINGFIELD IL
62701-1034
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-0706
  • Fax: 217-525-2535
Mailing address:
  • Phone: 217-788-0706
  • Fax: 217-525-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number085-003894
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-003894
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: