Provider Demographics
NPI:1891805503
Name:WICKLINE, EDDIE J (CRNA)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:J
Last Name:WICKLINE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 CALIFORNIA RD
Mailing Address - Street 2:STE A
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-0791
Mailing Address - Fax:574-262-9650
Practice Address - Street 1:2310 CALIFORNIA RD
Practice Address - Street 2:STE A
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1228
Practice Address - Country:US
Practice Address - Phone:574-264-0791
Practice Address - Fax:574-262-9650
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28137996A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200295510Medicaid
INCB1110AMedicare ID - Type Unspecified
S02810Medicare UPIN