Provider Demographics
NPI:1003265364
Name:WICKSTROM, ROSS S (CNP)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:S
Last Name:WICKSTROM
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1184 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2009
Mailing Address - Country:US
Mailing Address - Phone:937-382-1616
Mailing Address - Fax:
Practice Address - Street 1:1184 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2009
Practice Address - Country:US
Practice Address - Phone:937-382-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.19152363LF0000X
OHCOA.19152-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily