Provider Demographics
NPI:1629033352
Name:WYCKOFF, ELITA N (MD)
Entity Type:Individual
Prefix:MS
First Name:ELITA
Middle Name:N
Last Name:WYCKOFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:550 NEW WAVERLY PL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7412
Mailing Address - Country:US
Mailing Address - Phone:919-467-5941
Mailing Address - Fax:919-655-0532
Practice Address - Street 1:550 NEW WAVERLY PL
Practice Address - Street 2:SUITE 200
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7412
Practice Address - Country:US
Practice Address - Phone:919-467-5941
Practice Address - Fax:919-655-0532
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2005 00581207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902025Medicaid
NC5902025Medicaid
NC2045900Medicare ID - Type Unspecified