Healthcare Provider Details

I. General information

NPI: 1609425859
Provider Name (Legal Business Name): CORI WENZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E HENNICK ST
PINEDALE WY
82941-5228
US

IV. Provider business mailing address

PO BOX 69
AFTON WY
83110-0069
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-0099
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPT833
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: