Provider Demographics
NPI:1003506114
Name:WICKEY, KENNETH JAMES (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:WICKEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4567 HUNTON DALE RD NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-0283
Mailing Address - Country:US
Mailing Address - Phone:910-489-1739
Mailing Address - Fax:
Practice Address - Street 1:515 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WINGATE
Practice Address - State:NC
Practice Address - Zip Code:28174-8274
Practice Address - Country:US
Practice Address - Phone:704-233-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program