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NPI Code Detail

MEDICARE: MISS BONNIE BETH WICKHAM PA

MEDICARE: MISS BONNIE BETH WICKHAM PA
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
1363A00000XPhysician AssistantPA04799TX

General Provider Information

NPI Number : 1225058902
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS BONNIE BETH WICKHAM PA
Provider Business Mailing Address
First Line : PO BOX 22000
Second Line :
City : SAN ANGELO
State : TX
Zip : 76902-7200
Country : US
Telephone Number : 325-658-1511
Fax Number : 325-481-2104
Provider Business Practice Location Address
First Line : 61250 SE COOMBS PL
Second Line :
City : BEND
State : OR
Zip : 97702-3704
Country : US
Telephone Number : 541-706-5930
Fax Number : 541-706-5931
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2006
Last Update Date : 06/04/2026

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Directions to “ MISS BONNIE BETH WICKHAM PA” Practice Location

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