=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710172325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD WALTER WENDT PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2007
-----------------------------------------------------
Last Update Date | 09/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 W HAY ST STE 111
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-6328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-875-8100
-----------------------------------------------------
Fax | 217-872-5486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 W HAY ST STE 111
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-6328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-875-8100
-----------------------------------------------------
Fax | 217-872-5486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 085003029
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------