Provider Demographics
NPI:1477983724
Name:WONDRA, DOUGLAS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:WONDRA
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 1:294 HOUSE AVE
Mailing Address - Street 2:
Mailing Address - City:SANDIA
Mailing Address - State:TX
Mailing Address - Zip Code:78383-4098
Mailing Address - Country:US
Mailing Address - Phone:361-960-6213
Mailing Address - Fax:
Practice Address - Street 1:7101 S PADRE ISLAND DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-4913
Practice Address - Country:US
Practice Address - Phone:361-761-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-23
Last Update Date:2013-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX535397363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal