Provider Demographics
NPI:1538276001
Name:WUPPERMAN, PATRICK LEE (MD)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:LEE
Last Name:WUPPERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130189
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0189
Mailing Address - Country:US
Mailing Address - Phone:903-939-7500
Mailing Address - Fax:903-939-7728
Practice Address - Street 1:8101 S BROADWAY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5469
Practice Address - Country:US
Practice Address - Phone:903-939-7500
Practice Address - Fax:903-939-7728
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4666207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183593601Medicaid
TX183593601Medicaid
TX183593601Medicaid