Provider Demographics
NPI:1215983879
Name:WOLLUM, RONALD E III (PAC)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:E
Last Name:WOLLUM
Suffix:III
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3070 PRESIDENTIAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6293
Mailing Address - Country:US
Mailing Address - Phone:937-429-2160
Mailing Address - Fax:937-426-5663
Practice Address - Street 1:1416 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504
Practice Address - Country:US
Practice Address - Phone:937-322-1700
Practice Address - Fax:937-322-8070
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2018-08-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9106675363A00000X
OH50002301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA25205Medicare PIN
OHPA25204Medicare PIN
Q47484Medicare UPIN