Individual
JASON W. WICKERSHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
401 W GLYNN DR, PARKSTON, SD 57366-9605
(605) 928-3311
(605) 928-7368
Mailing address
401 W GLYNN DR, PARKSTON, SD 57366-9605
(605) 928-3311
(605) 928-7368
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
5450
SD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4995341
WELLMARK
SD
05
—
5340070
—
SD
05
—
5340340
—
SD
05
—
5611620
—
SD
Enumeration date
11/07/2005
Last updated
08/09/2012
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