Healthcare Provider Details

I. General information

NPI: 1134879372
Provider Name (Legal Business Name): AARON WICKARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3632 TULAGI ROAD
CORONADO CA
92118
US

IV. Provider business mailing address

34800 BOB WILSON DR # DT
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-545-7413
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number010278960
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: