Provider Demographics
NPI:1336180074
Name:WICKS, LOUISA DUKE (PA)
Entity Type:Individual
Prefix:
First Name:LOUISA
Middle Name:DUKE
Last Name:WICKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-6964
Mailing Address - Country:US
Mailing Address - Phone:501-268-3853
Mailing Address - Fax:501-268-3856
Practice Address - Street 1:705 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-6964
Practice Address - Country:US
Practice Address - Phone:501-268-3853
Practice Address - Fax:501-268-3856
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-377363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200825795Medicaid
AR200825795Medicaid