Provider Demographics
NPI:1699073999
Name:HASELOFF, WENDY C (PA-C)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:C
Last Name:HASELOFF
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 1:100 BOURLAND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3591
Mailing Address - Country:US
Mailing Address - Phone:817-379-5100
Mailing Address - Fax:817-379-0479
Practice Address - Street 1:100 BOURLAND RD STE 100
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3591
Practice Address - Country:US
Practice Address - Phone:817-379-5100
Practice Address - Fax:817-379-0479
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170258105Medicaid
TXTXB120326Medicare PIN
TXTXB127161Medicare PIN
TX170258105Medicaid