Provider Demographics
NPI:1407943939
Name:WICKMAN, DEBRA S (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:S
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:BYCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:15810 S 45TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7695
Mailing Address - Country:US
Mailing Address - Phone:480-827-5390
Mailing Address - Fax:602-521-5701
Practice Address - Street 1:15810 S 45TH ST STE 105
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7695
Practice Address - Country:US
Practice Address - Phone:480-827-5390
Practice Address - Fax:602-521-5701
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26444207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BW5868952OtherDEA