Provider Demographics
NPI:1215243027
Name:WUCKA, PAUL RYAN (DO)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RYAN
Last Name:WUCKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7222
Practice Address - Country:US
Practice Address - Phone:630-965-0996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125058721390200000X
NVSL0829207R00000X
IL036137508207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILRES000Medicare UPIN
IL125058721OtherSTATE LICENSE