Provider Demographics
NPI:1306587175
Name:WICK, BRIANA (PA-C)
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:WICK
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 1:224 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1520
Mailing Address - Country:US
Mailing Address - Phone:516-557-5003
Mailing Address - Fax:
Practice Address - Street 1:1726 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1512
Practice Address - Country:US
Practice Address - Phone:631-600-7878
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
NY025225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant