Basic Information
| Provider Information | |||||||||
| NPI: | 1093175358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WICKERSHAM | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER | ||||||||
| Address2: | 9040 JACKSON AVE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
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| Address1: | 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2016 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 1728 | NE | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.