Basic Information
| Provider Information | |||||||||
| NPI: | 1992706048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKERSHAM | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4345 W MEMORIAL RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054187000 | ||||||||
| FaxNumber: | 4054187099 | ||||||||
| Practice Location | |||||||||
| Address1: | 4345 W MEMORIAL RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054187000 | ||||||||
| FaxNumber: | 4054187099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 05/08/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20273 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 208VP0000X | 20273 | OK | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200036870A | 05 | OK | MEDICAID |