Provider Demographics
NPI:1417591025
Name:WICKSER, ROGER F (BS, QBHP)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:F
Last Name:WICKSER
Suffix:
Gender:M
Credentials:BS, QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 E JOYCE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5285
Mailing Address - Country:US
Mailing Address - Phone:479-757-9471
Mailing Address - Fax:479-587-9392
Practice Address - Street 1:707 N CARDINAL DR STE 7
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3274
Practice Address - Country:US
Practice Address - Phone:870-425-5644
Practice Address - Fax:870-425-2201
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR000Medicaid