Provider Demographics
NPI:1063012656
Name:WICKERHAM, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WICKERHAM
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:PO BOX 2263
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-2263
Mailing Address - Country:US
Mailing Address - Phone:701-278-1111
Mailing Address - Fax:701-477-8507
Practice Address - Street 1:9862 46TH AVE NE 1191 KENT ADDITION
Practice Address - Street 2:1191
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316
Practice Address - Country:US
Practice Address - Phone:701-278-1111
Practice Address - Fax:701-477-8507
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant