Healthcare Provider Details

I. General information

NPI: 1609147461
Provider Name (Legal Business Name): LEONARD TRENT WONNENBERG PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 4TH ST SE
HURON SD
57350-2510
US

IV. Provider business mailing address

172 4TH ST SE
HURON SD
57350-2590
US

V. Phone/Fax

Practice location:
  • Phone: 605-353-6200
  • Fax: 605-353-6300
Mailing address:
  • Phone: 605-353-6200
  • Fax: 605-353-6300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0803
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: