Provider Demographics
NPI:1881338903
Name:WACKER, SUE ANN
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ANN
Last Name:WACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 E US 190
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522
Mailing Address - Country:US
Mailing Address - Phone:254-238-7836
Mailing Address - Fax:
Practice Address - Street 1:1521 E. US 190
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522
Practice Address - Country:US
Practice Address - Phone:254-238-7836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209057208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47-3723846OtherMEDICARE