MEDICARE: DENISE ANN WIKSTEN PHD, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1649206269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE ANN WIKSTEN PHD, ATC

Provider Business Mailing Address
First Line	:	5500 CAMPANILE DR
Second Line	:	DEPT. OF EXERCISE & NUTRITIONAL SCIENCES
City	:	SAN DIEGO
State	:	CA
Zip	:	92182-0001
Country	:	US
Telephone Number	:	619-594-6825
Fax Number	:	619-594-6623

Provider Business Practice Location Address
First Line	:	5500 CAMPANILE DR
Second Line	:	DEPT. OF EXERCISE & NUTRITIONAL SCIENCES
City	:	SAN DIEGO
State	:	CA
Zip	:	92182-0001
Country	:	US
Telephone Number	:	619-594-6825
Fax Number	:	619-594-6623

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2006
Last Update Date	:	07/08/2007

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