Provider Demographics
NPI:1316933856
Name:WONNELL, JYL L (PA-C)
Entity type:Individual
Prefix:
First Name:JYL
Middle Name:L
Last Name:WONNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S 19TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-2902
Mailing Address - Country:US
Mailing Address - Phone:155-382-5413
Mailing Address - Fax:155-382-7107
Practice Address - Street 1:640 S 19TH ST STE 100
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:IA
Practice Address - Zip Code:50201
Practice Address - Country:US
Practice Address - Phone:515-382-5413
Practice Address - Fax:515-382-7107
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001551363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q23957OtherUPIN
IA5100837OtherCONTROLLED SUBSTANCE #
IA93389OtherIA BCBS SEEN IN RI
098863OtherHEALTH ALLIANCE
MW0685757OtherFEDERAL DEA#
ILIL01B1OtherJOHN DEERE EDI#
IA5100837OtherCONTROLLED SUBSTANCE #
MW0685757OtherFEDERAL DEA#
IA5100837OtherCONTROLLED SUBSTANCE #
IL141943Medicare ID - Type UnspecifiedMEDICARE UGS