Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | M3113 | TX |
NPI | 1053380048 |
---|---|
Provider Name | Dr. Pendleton Brewster Wickersham |
First Address | San Antonio, TX 78229-2263 |
Second Address | San Antonio, TX 78229-2263 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 01/02/2015 |