Healthcare Provider Details

I. General information

NPI: 1649741026
Provider Name (Legal Business Name): ADAM WICKHAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E MARKET ST
AKRON OH
44304-1619
US

IV. Provider business mailing address

11853 FARM CREEK AVE NW
UNIONTOWN OH
44685-6870
US

V. Phone/Fax

Practice location:
  • Phone: 330-375-6590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005800RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: