Provider Demographics
NPI:1265414965
Name:WICKWIRE, FREDERICK (CRNA)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:WICKWIRE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9834 NORTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-9343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7150 CLEARVISTA DRIVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1695
Practice Address - Country:US
Practice Address - Phone:317-621-5890
Practice Address - Fax:317-355-2205
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28115235A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000108959OtherANTHEM
IN100358680Medicaid
IN000000108959OtherANTHEM
INCA8070TMedicare PIN
INM400070991Medicare PIN
IN100358680Medicaid
IN215530LMedicare PIN