Provider Demographics
NPI:1124002555
Name:DEMPEWOLF, ANNA MARIE (PAC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:DEMPEWOLF
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:IA
Mailing Address - Zip Code:52342-2307
Mailing Address - Country:US
Mailing Address - Phone:641-484-5445
Mailing Address - Fax:641-753-2754
Practice Address - Street 1:1307 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:IA
Practice Address - Zip Code:52342-2307
Practice Address - Country:US
Practice Address - Phone:641-484-5445
Practice Address - Fax:641-753-2754
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS06802Medicare UPIN
IAI10079Medicare ID - Type Unspecified