Provider Demographics
NPI:1013415363
Name:WICKLOW, ERYN M (PA-C)
Entity Type:Individual
Prefix:
First Name:ERYN
Middle Name:M
Last Name:WICKLOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-1480 MOANIANI ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-4632
Mailing Address - Country:US
Mailing Address - Phone:808-432-3100
Mailing Address - Fax:
Practice Address - Street 1:94-1480 MOANIANI ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-4632
Practice Address - Country:US
Practice Address - Phone:808-432-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55117363A00000X
HIAMD-1154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant