Provider Demographics
NPI:1033197330
Name:WICKERT, KAREN (NP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:WICKERT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 WEST RD
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1637
Mailing Address - Country:US
Mailing Address - Phone:607-753-9977
Mailing Address - Fax:607-753-7311
Practice Address - Street 1:4077 WEST RD
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1637
Practice Address - Country:US
Practice Address - Phone:607-753-9977
Practice Address - Fax:607-753-7311
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331602363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC4659Medicare ID - Type Unspecified
NYP26744Medicare UPIN