Provider Demographics
NPI:1164068391
Name:WANCHA, RALF (NP)
Entity Type:Individual
Prefix:
First Name:RALF
Middle Name:
Last Name:WANCHA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 N BECKLEY AVE STE 152
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1586
Mailing Address - Country:US
Mailing Address - Phone:214-948-7700
Mailing Address - Fax:214-948-7701
Practice Address - Street 1:1947 K AVE STE A400
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5943
Practice Address - Country:US
Practice Address - Phone:972-535-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2019058471363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner