Basic Information
| Provider Information | |||||||||
| NPI: | 1669459970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WICKLINE | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 MIDDLE SETTLEMENT RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134135331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157354496 | ||||||||
| FaxNumber: | 3157357066 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 MIDDLE SETTLEMENT RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134135331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157354496 | ||||||||
| FaxNumber: | 3157357066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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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 | 207X00000X | 211832 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02237869 | 05 | NY | MEDICAID |