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NPI Code Detail

MEDICARE: TRISTAN C WICKHAM

MEDICARE: TRISTAN C WICKHAM
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
1225100000XPhysical Therapist

General Provider Information

NPI Number : 1215860028
Entity Type Code : Individual
Provider Name (Legal Business Name) : TRISTAN C WICKHAM
Provider Business Mailing Address
First Line : 136 S WARD ST
Second Line :
City : ELKHART
State : IN
Zip : 46514-2403
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2701 CHESTNUT STATION CT
Second Line :
City : LOUISVILLE
State : KY
Zip : 40299-6395
Country : US
Telephone Number : 800-335-1060
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/03/2026
Last Update Date : 06/03/2026

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Directions to “ TRISTAN C WICKHAM ” Practice Location

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