Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0205X | Pediatric Endocrinologist | 0101234906 | VA |
NPI | 1477566545 |
---|---|
Provider Name | Dr. Edmond P Wickham III |
First Address | Richmond, VA 23291-1734 |
Second Address | Richmond, VA 23298-5051 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 08/07/2007 |