Basic Information
| Provider Information | |||||||||
| NPI: | 1417591025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKSER | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | BS, QBHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2153 E JOYCE BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727035285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797579471 | ||||||||
| FaxNumber: | 4795879392 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N CARDINAL DR STE 7 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726533274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704255644 | ||||||||
| FaxNumber: | 8704252201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2019 | ||||||||
| LastUpdateDate: | 11/11/2019 | ||||||||
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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 | 171M00000X | AR | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 000 | 05 | AR | MEDICAID |