Provider Demographics
NPI:1992094767
Name:ROURK, WENDY (PA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:ROURK
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 1:222 W. LAS COLINAS BLVD
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039
Mailing Address - Country:US
Mailing Address - Phone:972-957-3000
Mailing Address - Fax:972-236-0096
Practice Address - Street 1:916 W. ILLINOIS AVE.
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-1855
Practice Address - Country:US
Practice Address - Phone:214-941-7611
Practice Address - Fax:214-941-7818
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB139778Medicare PIN
TX2862369-01Medicaid