MEDICARE: BONNIE LANE WOELTJEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA03492	TX
2	363AS0400X	Surgical Physician Assistant	085006025	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01068934	OTHER	TX	RR MEDICARE
3	P00278999	OTHER	TX	RAILROAD MEDICARE
8	P01253331	OTHER	TX	MEDICARE RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	616771101	OTHER		US DEPT OF LABOR
4	616771110	OTHER		US DEPT OF LABOR
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	616771105	OTHER		US DEPT OF LABOR
7	8N8791	OTHER	TX	BLUE CROSS BLUE SHIELD
9	601771109	OTHER		US DEPT OF LABOR

General Provider Information

NPI Number	:	1316983794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE LANE WOELTJEN PA-C

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE STE 1223
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1942 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1894
Country	:	US
Telephone Number	:	847-866-7846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	03/26/2026

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Directions to “ BONNIE LANE WOELTJEN PA-C” Practice Location

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