Provider Demographics
NPI:1417499898
Name:WUNSCHE, RANDY JAMES JR
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:JAMES
Last Name:WUNSCHE
Suffix:JR
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 1:4587 ASHLEY LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32967-2601
Mailing Address - Country:US
Mailing Address - Phone:772-633-3390
Mailing Address - Fax:
Practice Address - Street 1:4587 ASHLEY LAKE CIR
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32967-2601
Practice Address - Country:US
Practice Address - Phone:772-633-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20548225200000X
MA9264225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant