Individual
KELLY WICKSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
5301 E GRANT RD, TUCSON, AZ 85712-2805
(520) 324-5696
(520) 324-1583
Mailing address
1501 N CAMPBELL AVE RM 6336, BOX 245040, TUCSON, AZ 85724-5040
(520) 626-7000
(520) 626-6020
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
008816
AZ
207R00000X
Internal Medicine Physician
R2504
AZ
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
Primary
008816
AZ
207RP1001X
Pulmonary Disease Physician
008816
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
088520
—
AZ
Enumeration date
05/15/2015
Last updated
04/29/2023
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