Provider Demographics
NPI:1003506114
Name:WICKEY, KENNETH JAMES (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:WICKEY
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3158 FREEDOM DR STE 3101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-0014
Mailing Address - Country:US
Mailing Address - Phone:704-348-2992
Mailing Address - Fax:
Practice Address - Street 1:3158 FREEDOM DR STE 3102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-0014
Practice Address - Country:US
Practice Address - Phone:704-332-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant