Provider Demographics
NPI:1972849321
Name:WICKENHAUSER, KELSEY (PA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WICKENHAUSER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:EPPING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:8416 GANNON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-4907
Mailing Address - Country:US
Mailing Address - Phone:309-530-9841
Mailing Address - Fax:
Practice Address - Street 1:1368 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1685
Practice Address - Country:US
Practice Address - Phone:309-530-9841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037422363A00000X
IL085 005 018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant