Healthcare Provider Details

I. General information

NPI: 1730763152
Provider Name (Legal Business Name): RICHARD WNUK RT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 E LUPINE AVE
PHOENIX AZ
85028-2029
US

IV. Provider business mailing address

3249 E LUPINE AVE
PHOENIX AZ
85028-2029
US

V. Phone/Fax

Practice location:
  • Phone: 856-979-4062
  • Fax:
Mailing address:
  • Phone: 856-979-4062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number528772
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: