Healthcare Provider Details

I. General information

NPI: 1538658836
Provider Name (Legal Business Name): STEPHEN PAUL WICKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9228 MEDICAL PLAZA DR
CHARLESTON SC
29406-9125
US

IV. Provider business mailing address

9228 MEDICAL PLAZA DR
CHARLESTON SC
29406-9125
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-7080
  • Fax: 843-876-7111
Mailing address:
  • Phone: 843-876-7080
  • Fax: 843-876-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT1883
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: