Provider Demographics
NPI:1124278593
Name:WILSBACHER, JENNIFER FAE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FAE
Last Name:WILSBACHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WEGINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:818 5TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1303
Mailing Address - Country:US
Mailing Address - Phone:877-811-7526
Mailing Address - Fax:515-280-9525
Practice Address - Street 1:2304 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-4316
Practice Address - Country:US
Practice Address - Phone:877-811-7526
Practice Address - Fax:515-280-9525
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001931363A00000X
IA1082489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0057570Medicaid
IAA0249Medicare UPIN
IA0057570Medicaid