Provider Demographics
NPI:1669113734
Name:WICKMAN, CHANTAL BICH PHUONG (MD)
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:BICH PHUONG
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHANTAL
Other - Middle Name:BICH PHUONG
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1542 TULANE AVE # T4M2
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2865
Mailing Address - Country:US
Mailing Address - Phone:504-568-5600
Mailing Address - Fax:
Practice Address - Street 1:1542 TULANE AVE # T4M2
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2865
Practice Address - Country:US
Practice Address - Phone:504-568-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program