Provider Demographics
NPI:1346300266
Name:WICKHAM, CARA (PA)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARA
Other - Middle Name:
Other - Last Name:BEAUCHAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:
Practice Address - Street 1:1205 TROY SCHENECTADY RD STE 101
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1074
Practice Address - Country:US
Practice Address - Phone:518-348-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848171Medicaid
NYPA1758Medicare PIN
NYJ400052702Medicare PIN
NYP91193Medicare UPIN