Provider Demographics
NPI:1629037858
Name:WICHMAN, NOAH J (PA)
Entity Type:Individual
Prefix:
First Name:NOAH
Middle Name:J
Last Name:WICHMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WEEKS DR
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-3933
Mailing Address - Country:US
Mailing Address - Phone:336-598-5480
Mailing Address - Fax:336-598-5482
Practice Address - Street 1:107 WEEKS DR
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-3933
Practice Address - Country:US
Practice Address - Phone:336-598-5480
Practice Address - Fax:336-598-5482
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891005RMedicaid
NCNC4892AMedicare PIN
Q01799Medicare UPIN
NC2759643Medicare ID - Type Unspecified