Healthcare Provider Details

I. General information

NPI: 1497736789
Provider Name (Legal Business Name): WILLIAM JACOB WAHLERT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 EUBANK BLD NE STE C
ALBUQUERQUE NM
87111-3591
US

IV. Provider business mailing address

3825 EUBANK BLVD NE STE C
ALBUQUERQUE NM
87111-3591
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-8020
  • Fax: 505-292-5006
Mailing address:
  • Phone: 505-298-8020
  • Fax: 505-237-8803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number88PA17
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: