Healthcare Provider Details

I. General information

NPI: 1477983724
Provider Name (Legal Business Name): DOUGLAS WONDRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2013
Last Update Date: 11/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 S PADRE ISLAND DR
CORPUS CHRISTI TX
78412-4913
US

IV. Provider business mailing address

294 HOUSE AVE
SANDIA TX
78383-4098
US

V. Phone/Fax

Practice location:
  • Phone: 361-761-2020
  • Fax:
Mailing address:
  • Phone: 361-960-6213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number535397
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: