Provider Demographics
NPI:1780610915
Name:WICKERATH, JAMES R (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:WICKERATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 E CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-9442
Mailing Address - Country:US
Mailing Address - Phone:509-674-8511
Mailing Address - Fax:
Practice Address - Street 1:1706 E CAPITOL AVE
Practice Address - Street 2:VARIABLE SUBCONTRACTING CITIES AND STATES
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926
Practice Address - Country:US
Practice Address - Phone:509-674-3759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028905207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF28999Medicare UPIN