1316025356 NPI number — DR. MARIAREGINA LANDICHO WICKS MD

Table of content: DR. MARIAREGINA LANDICHO WICKS MD (NPI 1316025356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316025356 NPI number — DR. MARIAREGINA LANDICHO WICKS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKS
Provider First Name:
MARIAREGINA
Provider Middle Name:
LANDICHO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LANDICHO WICKS
Provider Other First Name:
GINA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1316025356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NAVAL HEALTH CLINIC OAK HARBOR 3475 NO SARATOGA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK HARBOR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98278-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-257-9501
Provider Business Mailing Address Fax Number:
360-257-9978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL HEALTH CLINIC OAK HARBOR 3475 NO SARATOGA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK HARBOR
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98278-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-257-9501
Provider Business Practice Location Address Fax Number:
360-257-9978
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  00023369 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8176398 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00023369 . This is a "WA MD LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 170322 . This is a "LABOR AND INDUSTRIES ID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: E47294 . This is a "MEDICARE UPIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7116841 . This is a "DSHS (PAYABLE GROUP)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: GAB38763 . This is a "MEDICARE PIN (PTAN)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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