Provider Demographics
NPI:1134519226
Name:WICKMAN, ELAINA (PA)
Entity type:Individual
Prefix:
First Name:ELAINA
Middle Name:
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELAINA
Other - Middle Name:
Other - Last Name:MCHENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17450 ST LUKES WAY STE 390
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-2001
Mailing Address - Country:US
Mailing Address - Phone:936-242-1437
Mailing Address - Fax:
Practice Address - Street 1:134 VISION PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3030
Practice Address - Country:US
Practice Address - Phone:936-242-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant