Healthcare Provider Details

I. General information

NPI: 1225058902
Provider Name (Legal Business Name): BONNIE BETH WICKHAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12039 E MAPLE SPRINGS WAY
PALMER AK
99645-9797
US

IV. Provider business mailing address

PO BOX 22000
SAN ANGELO TX
76902-7200
US

V. Phone/Fax

Practice location:
  • Phone: 907-745-9088
  • Fax: 833-464-5211
Mailing address:
  • Phone: 325-658-1511
  • Fax: 325-481-2104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04799
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: