Healthcare Provider Details

I. General information

NPI: 1508839499
Provider Name (Legal Business Name): NICHOLAS FRANCIS WUNDER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 HOSPITALITY WAY
ABERDEEN MD
21001-1755
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 410-306-7880
  • Fax: 410-306-7881
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002595
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: