Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | CH9310 | FL |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | ME118027 | FL |
NPI | 1184787228 |
---|---|
Provider Name | Dr. Eric D Wicks |
First Address | Lakeland, FL 33805 |
Second Address | Lakeland, FL 33803 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 15/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
V11258 | (02) | FL |