Provider Demographics
NPI:1407952542
Name:WICKS, MARY JO (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:WICKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:HAMMERSCHMDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 5501
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5501
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:701-323-5709
Practice Address - Street 1:938 2ND AVE W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3916
Practice Address - Country:US
Practice Address - Phone:701-456-6000
Practice Address - Fax:701-456-6101
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR26972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19746Medicaid
ND19746Medicaid
ND23415Medicare PIN