Healthcare Provider Details

I. General information

NPI: 1609833755
Provider Name (Legal Business Name): JEROME JOSEPH WENNINGER JR. PA-C MPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 01/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 S HIGHWAY 16
RAPID CITY SD
57702-8708
US

IV. Provider business mailing address

7220 S HIGHWAY 16
RAPID CITY SD
57702-8708
US

V. Phone/Fax

Practice location:
  • Phone: 605-341-1414
  • Fax:
Mailing address:
  • Phone: 605-341-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0975
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: