Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 09379 | IA |
NPI | 1114301231 |
---|---|
Provider Name | Chase Wicker |
First Address | Iowa City, IA 52242-1001 |
Second Address | Cedar Rapids, IA 52402-4831 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2015 |
Last Update Date | 24/01/2020 |