Provider Demographics
NPI:1982790721
Name:WICKHORST, SHELBY G (OD)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:G
Last Name:WICKHORST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 NE 162ND AVE STE D102
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-3010
Mailing Address - Country:US
Mailing Address - Phone:360-944-1911
Mailing Address - Fax:360-944-5255
Practice Address - Street 1:1901 NE 162ND AVE STE D102
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-3010
Practice Address - Country:US
Practice Address - Phone:360-944-1911
Practice Address - Fax:360-944-5255
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2027050Medicaid
WA2027050Medicaid