Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NR0400X | Rehabilitation Chiropractor | CHIR006263 | GA |
N | 111NX0800X | Chiropractor Orthopedic Specialist | CHIR006263 | GA |
NPI | 1629111505 |
---|---|
Provider Name | Dr. Paul V Wickster |
First Address | Athens, GA 30601-1853 |
Second Address | Athens, GA 30606-6006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U73990 | (02) | GA |