Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | A5695 | IA |
NPI | 1346240736 |
---|---|
Provider Name | Dr. Thomas A. Wicks |
First Address | Bettendorf, IA 52722-1828 |
Second Address | Davenport, IA 52803-5214 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2005 |
Last Update Date | 18/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
42064 | (02) | IA |