Individual
BLAKE WICKERHAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LAT, ATC
Contact information
Practice address
3121 WOODS PL, RALEIGH, NC 27607-5231
(919) 515-2111
Mailing address
3121 WOODS PL, RALEIGH, NC 27607-5231
(919) 515-2111
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2254
NC
Other
Enumeration date
03/07/2014
Last updated
03/07/2014
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