Provider Demographics
NPI:1326376328
Name:WICK, TAL D (EMT-B)
Entity Type:Individual
Prefix:MR
First Name:TAL
Middle Name:D
Last Name:WICK
Suffix:
Gender:M
Credentials:EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LYSTER ARMY HEALTH CLINIC
Mailing Address - Street 2:BLDG 301, ANDREWS AVE
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-7754
Mailing Address - Fax:
Practice Address - Street 1:LYSTER ARMY HEALTH CLINIC
Practice Address - Street 2:BLDG 301, ANDREWS AVE
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-7754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALB1719026146N00000X
246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic