Provider Demographics
NPI:1750074563
Name:WICKENBURG, LIAM ANDREW
Entity type:Individual
Prefix:MR
First Name:LIAM
Middle Name:ANDREW
Last Name:WICKENBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N MOONGLOW AVE
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2198
Mailing Address - Country:US
Mailing Address - Phone:707-666-1096
Mailing Address - Fax:
Practice Address - Street 1:631 N MOONGLOW AVE
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2198
Practice Address - Country:US
Practice Address - Phone:707-666-1096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant