Healthcare Provider Details

I. General information

NPI: 1972578672
Provider Name (Legal Business Name): GREGORY MATHEW WICKERN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 LOCUST ST N STE 600
TWIN FALLS ID
83301-4164
US

IV. Provider business mailing address

800 FALLS AVE SUITE #2
TWIN FALLS ID
83301-3366
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-6091
  • Fax: 208-734-4654
Mailing address:
  • Phone: 208-734-6091
  • Fax: 208-734-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number13018
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number6578473-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberM-10495
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: