Provider Demographics
NPI:1568460756
Name:WACKER, NIKKI ULLRICH (MD)
Entity Type:Individual
Prefix:DR
First Name:NIKKI
Middle Name:ULLRICH
Last Name:WACKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3041 CHURCHILL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-2706
Mailing Address - Country:US
Mailing Address - Phone:972-691-1240
Mailing Address - Fax:972-691-2073
Practice Address - Street 1:3041 CHURCHILL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022
Practice Address - Country:US
Practice Address - Phone:972-691-1240
Practice Address - Fax:972-691-2073
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9450208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147266404Medicaid
SC330458Medicaid
TX147266406Medicaid
TX147266407Medicaid
TX147266407Medicaid
TX147266406Medicaid
TX8J7061Medicare PIN
SCAA5956Medicare UPIN
SC330458Medicaid