Healthcare Provider Details

I. General information

NPI: 1750074563
Provider Name (Legal Business Name): MR. LIAM ANDREW WICKENBURG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S EAGLE RD STE 1241
MERIDIAN ID
83642-6355
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-6930
  • Fax: 208-381-6931
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8871273
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: