Provider Demographics
NPI:1962023911
Name:WICK, ANDREW JAMES
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:WICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3432 KINNAMON ROAD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104
Mailing Address - Country:US
Mailing Address - Phone:617-997-7959
Mailing Address - Fax:
Practice Address - Street 1:830 ROCKFORD STREET
Practice Address - Street 2:
Practice Address - City:MT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4220
Practice Address - Country:US
Practice Address - Phone:336-719-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261357390200000X
NC2022-02214207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program