Active NPI
Blake Wickerham, LAT, ATC
- Athletic Trainer
- Raleigh, NC
National Provider Identifier
1275959876
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 2254
- Practice address
- 3121 Woods PL
Raleigh, NC 27607-5231 - Phone
- (919) 515-2111
- NPI assigned
- Mar 7, 2014
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 2254 | NC | Primary |
Addresses
Primary practice location
3121 Woods PL
Raleigh, NC 27607-5231
Mailing address
3121 Woods PL
Raleigh, NC 27607-5231
Phone (919) 515-2111
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2254 | NC | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1394150400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1394150400000",
"number": "1275959876",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3121 WOODS PL",
"city": "RALEIGH",
"state": "NC",
"postal_code": "276075231",
"telephone_number": "919-515-2111"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3121 WOODS PL",
"city": "RALEIGH",
"state": "NC",
"postal_code": "276075231",
"telephone_number": "919-515-2111"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WICKERHAM",
"first_name": "BLAKE",
"credential": "LAT, ATC",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2014-03-07",
"last_updated": "2014-03-07",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "NC",
"license": "2254",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Raleigh, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.