Provider Demographics
NPI:1245990787
Name:WICKER, JEFFREY RYAN
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RYAN
Last Name:WICKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 GLENWOOD AVE SE UNIT 1710
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1890
Mailing Address - Country:US
Mailing Address - Phone:404-387-3012
Mailing Address - Fax:
Practice Address - Street 1:951 GLENWOOD AVE SE UNIT 1710
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1890
Practice Address - Country:US
Practice Address - Phone:404-387-3012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-24
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA192893363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine