Provider Demographics
NPI:1033996483
Name:WICKMAN, ALISON (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:
Last Name:WICKMAN
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 1:26325 PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3816
Mailing Address - Country:US
Mailing Address - Phone:734-751-7836
Mailing Address - Fax:
Practice Address - Street 1:26611 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-2063
Practice Address - Country:US
Practice Address - Phone:313-300-2549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011916363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant