Provider Demographics
NPI:1457694226
Name:WICKS, QUIANA (PA- C)
Entity Type:Individual
Prefix:MS
First Name:QUIANA
Middle Name:
Last Name:WICKS
Suffix:
Gender:F
Credentials:PA- C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 273
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-0273
Mailing Address - Country:US
Mailing Address - Phone:310-709-7694
Mailing Address - Fax:
Practice Address - Street 1:1250 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3026
Practice Address - Country:US
Practice Address - Phone:310-709-7694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-30
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22443363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant