Provider Demographics
NPI:1275281057
Name:WIERNICKI, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WIERNICKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5944 VISTA LINDA LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-8230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5944 VISTA LINDA LN
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-8230
Practice Address - Country:US
Practice Address - Phone:561-245-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL149630367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty