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General NPI Number Information
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NPI Number | 1972578672
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Entity Type | Individual
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Provider Name | GREGORY MATHEW WICKERN M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/17/2006
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Last Update Date | 11/17/2020
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Provider Practice Location Address
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Address Line | 1502 LOCUST ST N STE 600
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City | TWIN FALLS
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State | ID
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Zip | 83301-4164
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Country | US
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Telephone | 208-734-6091
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Fax | 208-734-4654
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Provider Business Mailing Address
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Address Line | 800 FALLS AVE SUITE #2
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City | TWIN FALLS
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State | ID
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Zip | 83301-3366
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Country | US
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Telephone | 208-734-6091
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Fax | 208-734-4654
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 13018
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 6578473-1205
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License Number State | UT
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Taxonomy #3
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | M-10495
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License Number State | ID
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