Provider Demographics
NPI:1568465722
Name:WICKE, AMY (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WICKE
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 1:100 W DEAN KEETON ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1091
Mailing Address - Country:US
Mailing Address - Phone:512-471-4955
Mailing Address - Fax:
Practice Address - Street 1:100 W DEAN KEETON ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1091
Practice Address - Country:US
Practice Address - Phone:512-471-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04282363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194812701Medicaid
1114004462OtherGROUP NPI
TX00160ZOtherMEDICARE GROUP
TX194812701Medicaid