Healthcare Provider Details

I. General information

NPI: 1285162693
Provider Name (Legal Business Name): MARY ELIZABETH WICKLINE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 JAMES MONROE DR
LINDSIDE WV
24951-7168
US

IV. Provider business mailing address

PO BOX 590
UNION WV
24983-0590
US

V. Phone/Fax

Practice location:
  • Phone: 304-753-5940
  • Fax: 304-753-5941
Mailing address:
  • Phone: 304-772-3064
  • Fax: 304-772-3296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: