Provider Demographics
NPI:1225058902
Name:WICKHAM, BONNIE BETH (PA)
Entity Type:Individual
Prefix:MISS
First Name:BONNIE
Middle Name:BETH
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:325-481-2104
Practice Address - Street 1:402 W 26TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-2826
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:325-481-2166
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400001542Medicare PIN