Provider Demographics
NPI:1427107580
Name:SUBASIC, WENDY JO (PA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:JO
Last Name:SUBASIC
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5421
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:
Practice Address - Street 1:3407 WILKENS AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5072
Practice Address - Country:US
Practice Address - Phone:410-644-0929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDMD0003372363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ777Medicare PIN
MD988LQ777Medicare PIN