Provider Demographics
NPI:1477701910
Name:WICKS, RACHEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:L
Last Name:WICKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-371-1717
Mailing Address - Fax:814-375-4422
Practice Address - Street 1:145 HOSPITAL AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1462
Practice Address - Country:US
Practice Address - Phone:814-371-1717
Practice Address - Fax:814-375-4422
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053544363A00000X
NY013269-1363AM0700X
PAOA002917363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA135971D7AMedicare PIN