Healthcare Provider Details

I. General information

NPI: 1811261514
Provider Name (Legal Business Name): NICOLE A. WUNDERLICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2012
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 FANNIN ST
HOUSTON TX
77030-2608
US

IV. Provider business mailing address

2450 HOLCOMBE BLVD STE NB-34L
HOUSTON TX
77021-2039
US

V. Phone/Fax

Practice location:
  • Phone: 832-824-1000
  • Fax:
Mailing address:
  • Phone: 832-828-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: