Provider Demographics
NPI:1346286986
Name:WICKS, BRIAN P (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:WICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7681
Practice Address - Country:US
Practice Address - Phone:360-830-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027475207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8937342OtherCRIME VICTIMS COMP
WA8117954Medicaid
200007065OtherRAILROAD MEDICARE
4587297OtherAETNA
WI9576OtherREGENCE BLUE SHIELD
WA75451OtherLABOR & INDUSTRIES
WA75451OtherLABOR & INDUSTRIES
WAG8851970Medicare PIN
WAG000250607Medicare PIN
E01941Medicare UPIN
WAG000250438Medicare PIN
BW1768918OtherDEA
WA8937342OtherCRIME VICTIMS COMP
200007065OtherRAILROAD MEDICARE
WA8117954Medicaid