Provider Demographics
NPI:1861582710
Name:WHEELER, GWENDOLYN (PA-C)
Entity type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
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 1:1091 S BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-8372
Mailing Address - Country:US
Mailing Address - Phone:352-476-6482
Mailing Address - Fax:
Practice Address - Street 1:201 INDEPENDENCE DRIVE
Practice Address - Street 2:14 MDG
Practice Address - City:COLUMBUS AFB
Practice Address - State:MS
Practice Address - Zip Code:39710
Practice Address - Country:US
Practice Address - Phone:662-434-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14190363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical