Healthcare Provider Details

I. General information

NPI: 1609331560
Provider Name (Legal Business Name): FREDERICK WYCOCO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 ALTA RD # 5300
SAN DIEGO CA
92158-0001
US

IV. Provider business mailing address

446 ALTA RD # 5300
SAN DIEGO CA
92158-0001
US

V. Phone/Fax

Practice location:
  • Phone: 619-661-2789
  • Fax: 505-499-4988
Mailing address:
  • Phone: 619-661-2789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95010473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: