Provider Demographics
NPI:1336724236
Name:WICKLIFFE, GARRY WAYNE JR (LSA, CST)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:WAYNE
Last Name:WICKLIFFE
Suffix:JR
Gender:M
Credentials:LSA, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 KAYNELL DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75654-4718
Mailing Address - Country:US
Mailing Address - Phone:936-635-3169
Mailing Address - Fax:
Practice Address - Street 1:704 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2014
Practice Address - Country:US
Practice Address - Phone:903-646-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00957246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant