Provider Demographics
NPI:1417316480
Name:WICKES, ZACH (ATC)
Entity Type:Individual
Prefix:
First Name:ZACH
Middle Name:
Last Name:WICKES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 N VAN
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143
Mailing Address - Country:US
Mailing Address - Phone:903-491-6900
Mailing Address - Fax:
Practice Address - Street 1:506 N VAN
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143
Practice Address - Country:US
Practice Address - Phone:903-491-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2000022913390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program