Provider Demographics
NPI:1316025356
Name:WICKS, MARIAREGINA LANDICHO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIAREGINA
Middle Name:LANDICHO
Last Name:WICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:LANDICHO WICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:NAVAL HEALTH CLINIC OAK HARBOR 3475 NO SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98278-0001
Mailing Address - Country:US
Mailing Address - Phone:360-257-9501
Mailing Address - Fax:360-257-9978
Practice Address - Street 1:NAVAL HEALTH CLINIC OAK HARBOR 3475 NO SARATOGA ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98278-0001
Practice Address - Country:US
Practice Address - Phone:360-257-9501
Practice Address - Fax:360-257-9978
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00023369207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8176398Medicaid
WA00023369OtherWA MD LICENSE
WA170322OtherLABOR AND INDUSTRIES ID
WAE47294OtherMEDICARE UPIN
WA7116841OtherDSHS (PAYABLE GROUP)
WAGAB38763OtherMEDICARE PIN (PTAN)
WAGAB38763OtherMEDICARE PIN (PTAN)
WA00023369OtherWA MD LICENSE
WAGAB38763OtherMEDICARE PIN (PTAN)