Provider Demographics
NPI:1528195310
Name:WRUCK, ERIC (DC, FNP-C)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:WRUCK
Suffix:
Gender:M
Credentials:DC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1140
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-1140
Mailing Address - Country:US
Mailing Address - Phone:808-873-0733
Mailing Address - Fax:
Practice Address - Street 1:95 LONO AVE STE 105
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1610
Practice Address - Country:US
Practice Address - Phone:808-873-0733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-2874363L00000X
HIDC-726111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIU73522Medicare UPIN