Healthcare Provider Details

I. General information

NPI: 1164068391
Provider Name (Legal Business Name): RALF WANCHA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 K AVE STE A400
PLANO TX
75074-5943
US

IV. Provider business mailing address

1411 N BECKLEY AVE STE 152
DALLAS TX
75203-1586
US

V. Phone/Fax

Practice location:
  • Phone: 972-535-5099
  • Fax:
Mailing address:
  • Phone: 214-948-7700
  • Fax: 214-948-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2019058471
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: