MEDICARE: MARY ELIZABETH WICKLINE PA-C

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1285162693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELIZABETH WICKLINE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 590
Second Line	:
City	:	UNION
State	:	WV
Zip	:	24983-0590
Country	:	US
Telephone Number	:	304-772-3064
Fax Number	:	304-772-3296

Provider Business Practice Location Address
First Line	:	142 JAMES MONROE DR
Second Line	:
City	:	LINDSIDE
State	:	WV
Zip	:	24951-7168
Country	:	US
Telephone Number	:	304-753-5940
Fax Number	:	304-753-5941

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

Provider Enumeration Date	:	05/30/2017
Last Update Date	:	01/29/2025

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