Individual
REGINALD KEITH WICKER III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
497 AZALEA DR STE 102, OXFORD, MS 38655-7901
(662) 513-2000
(662) 232-0004
Mailing address
497 AZALEA DR STE 102, OXFORD, MS 38655-7901
(662) 513-2000
(662) 232-0004
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT2994
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09058871
—
MS
01
—
582681044
TAX ID #
MS
Enumeration date
01/03/2007
Last updated
09/25/2024
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