Provider Demographics
NPI:1215460068
Name:WENIG, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WENIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3216
Mailing Address - Country:US
Mailing Address - Phone:866-884-3135
Mailing Address - Fax:
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:866-884-3135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-09
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8132621207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology