Individual
ALVAH TYSON WICKBOLDT JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1514 JEFFERSON HWY, BRENT HOUSE ROOM 634, NEW ORLEANS, LA 70121-2429
(504) 842-3000
Mailing address
1514 JEFFERSON HIGHWAY, NEW ORLEANS, LA 70121-2429
(504) 842-3000
Taxonomy
Speciality
Code
Description
License number
State
208VP0000X
Pain Medicine Physician
Primary
305062
LA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/15/2012
Last updated
07/21/2022
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