Provider Demographics
NPI:1912137977
Name:WICKSTRUM, ANGELA K (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:K
Last Name:WICKSTRUM
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 9101
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-9494
Mailing Address - Country:US
Mailing Address - Phone:972-745-7500
Mailing Address - Fax:972-745-4336
Practice Address - Street 1:5301 WILLIAM D TATE AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7357
Practice Address - Country:US
Practice Address - Phone:817-251-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant