Provider Demographics
NPI:1164457073
Name:WICK, NANCY A (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:WICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GRAYSON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3745
Mailing Address - Country:US
Mailing Address - Phone:757-473-3200
Mailing Address - Fax:
Practice Address - Street 1:200 GRAYSON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3745
Practice Address - Country:US
Practice Address - Phone:757-473-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241709208000000X
GA0506912080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1164457073Medicaid
G82415Medicare UPIN