MEDICARE: WADE WYCKOFF

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	208100000X	Physical Medicine & Rehabilitation Physician	346157	LA

General Provider Information

NPI Number	:	1689243149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WADE WYCKOFF

Provider Business Mailing Address
First Line	:	1111 LINE AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71101-3841
Country	:	US
Telephone Number	:	318-716-4545
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 LINE AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71101-3841
Country	:	US
Telephone Number	:	318-716-4545
Fax Number	:

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

Provider Enumeration Date	:	06/20/2021
Last Update Date	:	10/14/2025

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Directions to “ WADE WYCKOFF ” Practice Location

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