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NPI Code Detail

MEDICARE: MS. ANGELA K WICKSTRUM PA-C

MEDICARE: MS. ANGELA K WICKSTRUM PA-C
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
1363A00000XPhysician AssistantPA04934TX

General Provider Information

NPI Number : 1912137977
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. ANGELA K WICKSTRUM PA-C
Provider Business Mailing Address
First Line : PO BOX 746079
Second Line :
City : ATLANTA
State : GA
Zip : 30374-6079
Country : US
Telephone Number : 773-352-1515
Fax Number : 312-929-0373
Provider Business Practice Location Address
First Line : 4115 E LANCASTER AVE
Second Line :
City : FORT WORTH
State : TX
Zip : 76103-3614
Country : US
Telephone Number : 817-369-8526
Fax Number : 817-764-0714
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/23/2009
Last Update Date : 09/18/2025

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