Provider Demographics
NPI:1164510798
Name:WICKER, HOLLIE (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:
Last Name:WICKER
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-4374
Mailing Address - Fax:515-643-2784
Practice Address - Street 1:1601 NW 114TH ST
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7007
Practice Address - Country:US
Practice Address - Phone:515-222-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA70932OtherWELLMARK BLUE SHIELD
IA27468OtherWELLMARK BLUE SHIELD
IAP000429806OtherRAILROAD MEDICARE
IA70932OtherWELLMARK BLUE SHIELD
IAP000429806OtherRAILROAD MEDICARE