Provider Demographics
NPI:1336146216
Name:WICKENKAMP, SARAH K (M D)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:K
Last Name:WICKENKAMP
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 10TH ST SE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2442
Mailing Address - Country:US
Mailing Address - Phone:319-363-3600
Mailing Address - Fax:319-363-9971
Practice Address - Street 1:411 10TH ST SE
Practice Address - Street 2:SUITE 150
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2442
Practice Address - Country:US
Practice Address - Phone:319-363-3600
Practice Address - Fax:319-363-9971
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26381208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1055772Medicaid
IA182337OtherWELLMARK BCBS
IAD89674Medicare UPIN