Healthcare Provider Details

I. General information

NPI: 1275088031
Provider Name (Legal Business Name): SHERMAN WAYNE WIENEKE AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229
US

IV. Provider business mailing address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-8555
  • Fax: 210-358-8576
Mailing address:
  • Phone: 210-358-8555
  • Fax: 210-358-8576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number0187139
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP131815
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: