Provider Demographics
NPI:1083092589
Name:WICKSTROM, KELLY (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1501 N CAMPBELL AVE RM 6336
Mailing Address - Street 2:BOX 245040
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85724-5040
Mailing Address - Country:US
Mailing Address - Phone:520-626-7000
Mailing Address - Fax:520-626-6020
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-324-5696
Practice Address - Fax:520-324-1583
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2023-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ008816207R00000X, 207RP1001X, 207RC0200X
AZR2504207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ088520Medicaid