Basic Information
| Provider Information | |||||||||
| NPI: | 1801989165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICK | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | ARLENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLIOTT | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5530 WISCONSIN AVE | ||||||||
| Address2: | SUITE 1660 | ||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016579876 | ||||||||
| FaxNumber: | 3016578240 | ||||||||
| Practice Location | |||||||||
| Address1: | 5530 WISCONSIN AVE | ||||||||
| Address2: | SUITE 1660 | ||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208154404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016579876 | ||||||||
| FaxNumber: | 3016578240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2006 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA030404 | DC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | C0003208 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.