Provider Demographics
NPI:1477856979
Name:WUNDERLICH, MARY O (PA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:O
Last Name:WUNDERLICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278
Mailing Address - Country:US
Mailing Address - Phone:618-282-3831
Mailing Address - Fax:618-282-5476
Practice Address - Street 1:325 SPRING STREET
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278
Practice Address - Country:US
Practice Address - Phone:618-282-3831
Practice Address - Fax:618-282-5476
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000332363AM0700X
IL085000332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical