Healthcare Provider Details

I. General information

NPI: 1487190252
Provider Name (Legal Business Name): JAIDEN WYKOFF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAIDEN HUMBLES PA-C

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MDG/SGHC UNIT 5115
APO AE
09461-5115
US

IV. Provider business mailing address

RAF LAKENHEATH 48 MDG UNIT 5210 BOX 230
APO AE
09461-0230
US

V. Phone/Fax

Practice location:
  • Phone: 01638522268010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: