Provider Demographics
NPI:1730735259
Name:WOLFGANG, LAWRENCE LOUIS (PA-C)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:LOUIS
Last Name:WOLFGANG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 BEAVER DAM RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17921-9038
Mailing Address - Country:US
Mailing Address - Phone:570-985-7685
Mailing Address - Fax:
Practice Address - Street 1:501 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4810
Practice Address - Country:US
Practice Address - Phone:393-081-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant