Provider Demographics
NPI:1609331560
Name:WYCOCO, FREDERICK (NP)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:WYCOCO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 ALTA RD # 5300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92158-0001
Mailing Address - Country:US
Mailing Address - Phone:619-661-2789
Mailing Address - Fax:
Practice Address - Street 1:446 ALTA RD # 5300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92158-0001
Practice Address - Country:US
Practice Address - Phone:619-661-2789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010473363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily