Provider Demographics
NPI:1831687300
Name:WENNER, KEVIN WALTER (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:WALTER
Last Name:WENNER
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 1:430 BATH RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2656
Mailing Address - Country:US
Mailing Address - Phone:207-442-0350
Mailing Address - Fax:207-618-5668
Practice Address - Street 1:430 BATH RD STE 102
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2656
Practice Address - Country:US
Practice Address - Phone:207-442-0350
Practice Address - Fax:207-618-5668
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6455363A00000X, 363AM0700X, 363AS0400X
MEPA2143363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical