Provider Demographics
NPI:1417025636
Name:WICKWARE, TRACY L (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:WICKWARE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 4TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3119
Mailing Address - Country:US
Mailing Address - Phone:619-297-9610
Mailing Address - Fax:619-297-2244
Practice Address - Street 1:3930 4TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3119
Practice Address - Country:US
Practice Address - Phone:619-297-9610
Practice Address - Fax:619-297-2244
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 17814OtherCALIFORNIA LICENSE
CAPA 17814OtherCALIFORNIA LICENSE