Provider Demographics
NPI:1760923874
Name:WURSTER, RICHARD (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WURSTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:WURSTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1640 AINSDALE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-5838
Mailing Address - Country:US
Mailing Address - Phone:916-759-2000
Mailing Address - Fax:
Practice Address - Street 1:1640 AINSDALE DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-5838
Practice Address - Country:US
Practice Address - Phone:916-759-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19666174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist