Provider Demographics
NPI:1003285693
Name:WICKHAM, GRAYSON
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 81ST ST
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:667 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-8029
Practice Address - Country:US
Practice Address - Phone:877-474-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist