Basic Information
| Provider Information | |||||||||
| NPI: | 1184003295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WICKS | ||||||||
| FirstName: | JOSHUA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 380 CHASE AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.