MEDICARE: EMILY LOUISE WICKERSHAM DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	036.177695	IL
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	2024028249	MO

General Provider Information

NPI Number	:	1093175358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY LOUISE WICKERSHAM DO

Provider Business Mailing Address
First Line	:	19135 PAWNEE CT
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64505-8901
Country	:	US
Telephone Number	:	309-258-5813
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 N OAKLAND AVE
Second Line	:
City	:	BOLIVAR
State	:	MO
Zip	:	65613-3099
Country	:	US
Telephone Number	:	417-326-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2016
Last Update Date	:	01/15/2026

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