Provider Demographics
NPI:1023809951
Name:WICKER, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:WICKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 N MAIN ST # 7803
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45314-8501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 N MAIN ST # 7803
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:OH
Practice Address - Zip Code:45314-8501
Practice Address - Country:US
Practice Address - Phone:937-766-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant