Provider Demographics
NPI:1306895206
Name:WAHLERS, BRENDA M (MD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:WAHLERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COUDERSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16915-8161
Mailing Address - Country:US
Mailing Address - Phone:814-274-9300
Mailing Address - Fax:814-274-0807
Practice Address - Street 1:1001 E 2ND ST
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915-8161
Practice Address - Country:US
Practice Address - Phone:814-274-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426164207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013188780001Medicaid
PAI33716Medicare UPIN
PA1013188780001Medicaid