Provider Demographics
NPI:1952468407
Name:WICKER, REGINALD KEITH III (PT)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:KEITH
Last Name:WICKER
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:TREY
Other - Middle Name:
Other - Last Name:WICKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:206B OXFORD RD
Mailing Address - Street 2:PO BOX 44
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-4445
Mailing Address - Fax:662-534-9449
Practice Address - Street 1:710 CITY AVE N
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1615
Practice Address - Country:US
Practice Address - Phone:662-837-6060
Practice Address - Fax:662-837-4060
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS582681044OtherTAX ID #
MS09058871Medicaid
MS256599Medicare ID - Type UnspecifiedMEDICARE