Basic Information
| Provider Information | |||||||||
| NPI: | 1609062496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKS | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | STEWART | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | STEWART | ||||||||
| OtherFirstName: | CHELSEA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 780 KUENZLI ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895020845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759824590 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 PRINGLE WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825000 | ||||||||
| FaxNumber: | 7759826021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
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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 | 208000000X | 12411 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 11934134 | 01 | CAQH | OTHER | 1609062496 | 05 | NV | MEDICAID |