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General NPI Number Information
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NPI Number | 1497736789
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Entity Type | Individual
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Provider Name | WILLIAM JACOB WAHLERT PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/14/2005
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Last Update Date | 01/21/2011
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Provider Practice Location Address
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Address Line | 3825 EUBANK BLD NE STE C
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City | ALBUQUERQUE
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State | NM
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Zip | 87111-3591
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Country | US
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Telephone | 505-298-8020
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Fax | 505-292-5006
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Provider Business Mailing Address
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Address Line | 3825 EUBANK BLVD NE STE C
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City | ALBUQUERQUE
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State | NM
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Zip | 87111-3591
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Country | US
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Telephone | 505-298-8020
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Fax | 505-237-8803
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 88PA17
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License Number State | NM
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