Provider Demographics
NPI:1013977586
Name:WICKISER, DANIEL N (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:N
Last Name:WICKISER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 SAMPSON ST
Mailing Address - Street 2:P.O.BOX 277
Mailing Address - City:WESTLAKE
Mailing Address - State:LA
Mailing Address - Zip Code:70669-5311
Mailing Address - Country:US
Mailing Address - Phone:337-436-3145
Mailing Address - Fax:337-436-5435
Practice Address - Street 1:902 SAMPSON ST
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:LA
Practice Address - Zip Code:70669-5311
Practice Address - Country:US
Practice Address - Phone:337-436-3145
Practice Address - Fax:377-436-5435
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA745111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11352742OtherCAQH
LA11352742OtherCAQH
LA59418Medicare ID - Type Unspecified
LAT86136Medicare UPIN