=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841595097
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDER JASON WICKER PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2011
-----------------------------------------------------
Last Update Date | 08/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 E MERRICK RD
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-887-5500
-----------------------------------------------------
Fax | 516-887-5509
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 CARRIAGE RD
-----------------------------------------------------
City | ROSLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11576-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-741-2998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------