Active NPI
Garry Wayne Wickliffe Jr., LSA, CST
- Surgical Assistant
- Tyler, TX
National Provider Identifier
1336724236
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgical Assistant
- License
- SA00957
- Practice address
- 704 S Fleishel Ave
Tyler, TX 75701-2014 - Phone
- (903) 646-5350
- NPI assigned
- Mar 11, 2021
- Sex
- Male
- Sole proprietor
- No
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 |
|---|---|---|---|---|
| Surgical Assistant | 246ZC0007X | SA00957 | TX | Primary |
Addresses
Primary practice location
704 S Fleishel Ave
Tyler, TX 75701-2014
Mailing address
2320 Kaynell Dr
Henderson, TX 75654-4718
Phone (936) 635-3169
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 |
|---|---|---|---|
| SA00957 | TX | MD | Surgical Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1615420800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1711843200000",
"number": "1336724236",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2320 KAYNELL DR",
"city": "HENDERSON",
"state": "TX",
"postal_code": "756544718",
"telephone_number": "936-635-3169"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "704 S FLEISHEL AVE",
"city": "TYLER",
"state": "TX",
"postal_code": "757012014",
"telephone_number": "903-646-5350"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WICKLIFFE",
"first_name": "GARRY",
"middle_name": "WAYNE",
"name_suffix": "Jr.",
"credential": "LSA, CST",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-03-11",
"last_updated": "2024-03-31",
"certification_date": "2024-03-31",
"status": "A"
},
"taxonomies": [
{
"code": "246ZC0007X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Other, Surgical Assistant",
"state": "TX",
"license": "SA00957",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tyler, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.