Basic Information
| Provider Information | |||||||||
| NPI: | 1164510798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKER | ||||||||
| FirstName: | HOLLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156434374 | ||||||||
| FaxNumber: | 5156432784 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 NW 114TH ST | ||||||||
| Address2: | |||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503257007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152227000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/12/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001753 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 70932 | 01 | IA | WELLMARK BLUE SHIELD | OTHER | 27468 | 01 | IA | WELLMARK BLUE SHIELD | OTHER | P000429806 | 01 | IA | RAILROAD MEDICARE | OTHER |