Basic Information
| Provider Information | |||||||||
| NPI: | 1659393759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENNER | ||||||||
| FirstName: | KARL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 DAGGETT AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412746564 | ||||||||
| FaxNumber: | 5412746247 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 DAGGETT AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412746733 | ||||||||
| FaxNumber: | 5412742006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD15968 | OR | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | MD15968 | OR | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | XPY113830 | 01 | OR | MEDI-CAL | OTHER | AW3278808 | 01 | OR | DEA | OTHER | 098830 | 05 | OR | MEDICAID |