Provider Demographics
NPI:1790196392
Name:WICKLUND, KARI (PA-C)
Entity Type:Individual
Prefix:
First Name:KARI
Middle Name:
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4110
Mailing Address - Country:US
Mailing Address - Phone:817-922-4650
Mailing Address - Fax:817-922-4655
Practice Address - Street 1:1250 8TH AVE STE 265
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4124
Practice Address - Country:US
Practice Address - Phone:682-200-8580
Practice Address - Fax:682-200-8581
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA09171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant