Provider Demographics
NPI:1629111505
Name:WICKSTER, PAUL V (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:V
Last Name:WICKSTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 NEW ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-1853
Mailing Address - Country:US
Mailing Address - Phone:706-227-3325
Mailing Address - Fax:706-369-9800
Practice Address - Street 1:1590 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6006
Practice Address - Country:US
Practice Address - Phone:706-227-3325
Practice Address - Fax:706-369-9800
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006263111NR0400X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitation
Not Answered111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU73990Medicare UPIN
GA35ZCFMCMedicare ID - Type UnspecifiedMEDICARE