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1952468407 NPI number — REGINALD KEITH WICKER III PT

NPI Number: 1952468407
Health Care Provider/Practitioner: REGINALD KEITH WICKER III PT

Information about “1952468407” NPI (REGINALD KEITH WICKER III PT) exists in 1952468407 in HTML format HTML  |  1952468407 in plain Text format TXT  |  1952468407 in PDF (Portable Document Format) PDF  |  1952468407 in an XML format XML  formats.

NPI Number : 1952468407 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1952468407",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "WICKER",
    "FirstName": "REGINALD",
    "MiddleName": "KEITH",
    "NamePrefix": null,
    "NameSuffix": "III",
    "Credential": "PT",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "WICKER",
    "OtherFirstName": "TREY",
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": "PT",
    "OtherLastNameTypeCode": "5",
    "FirstLineMailingAddress": "497 AZALEA DR STE 102",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "OXFORD",
    "MailingAddressStateName": "MS",
    "MailingAddressPostalCode": "38655-7901",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "662-513-2000",
    "MailingAddressFaxNumber": "662-232-0004",
    "FirstLinePracticeLocationAddress": "497 AZALEA DR STE 102",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "OXFORD",
    "PracticeLocationAddressStateName": "MS",
    "PracticeLocationAddressPostalCode": "38655-7901",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "662-513-2000",
    "PracticeLocationAddressFaxNumber": "662-232-0004",
    "EnumerationDate": "01/03/2007",
    "LastUpdateDate": "09/25/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "225100000X",
        "TaxonomyName": "Physical Therapist",
        "LicenseNumber": "PT2994",
        "LicenseNumberStateCode": "MS",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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