Healthcare Provider Details

I. General information

NPI: 1831186303
Provider Name (Legal Business Name): JONATHAN WOLKWITZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E. 2ND
DEXTER NM
88230
US

IV. Provider business mailing address

7100 COMMERCE WAY SUITE 180
BRENTWOOD TN
37027-2829
US

V. Phone/Fax

Practice location:
  • Phone: 575-734-5817
  • Fax: 575-734-6550
Mailing address:
  • Phone: 615-465-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number96-PA22
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number96-PA22
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: