Kyle Rollin Wicks, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

Practice address

2570 NW Edenbower Blvd Ste 100
Roseburg, OR 97471-6214

Phone

(541) 677-7200

Fax

(541) 229-3309

NPI assigned

Aug 31, 2020

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2020

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Centennial Medical Group East LLCGroup PAC ID 9234397878, 63 clinicians

Evergreen Family Medicine PCGroup PAC ID 3870485139, 55 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Mercy Medical Center Hospital, Roseburg, OR, CCN 380027

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kyle.wicks.1@1334.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Centennial Medical Group East, LLC

  • Family Medicine Physician
  • Roseburg, OR
  • NPI 1134436637
  Medicare reassignment Care Compare group
• Evergreen Family Medicine, PC

  • Family Medicine Physician
  • Roseburg, OR
  • NPI 1417929050
  Care Compare group
• Centennial Medical Group East, LLC

  • Obstetrics & Gynecology Physician
  • Roseburg, OR
  • NPI 1134243249
  NPD
• Centennial Medical Group East, LLC

  • Family Medicine Physician
  • Sutherlin, OR
  • NPI 1164124111
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Commonspirit Oregon

  • General Acute Care Hospital
  • Roseburg, OR
  • NPI 1477590198
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1598832000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1675641600000",
    "number": "1750995577",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD STE 100",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974716214",
            "telephone_number": "541-677-7200",
            "fax_number": "541-229-3309"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD STE 100",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974716214",
            "telephone_number": "541-677-7200",
            "fax_number": "541-229-3309"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WICKS",
        "first_name": "KYLE",
        "middle_name": "ROLLIN",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-08-31",
        "last_updated": "2023-02-06",
        "certification_date": "2023-02-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500804257",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Trevar John White
• Rachael Whiteberg
• Karla Whitlock, MA, LPC
• Adrienne Wicker, CADC-R, CGAC II, CRM
• Sarah Wickersham-Keller, BS
• Linda G Widener
• Gerald Wieland, PHARMACIST
• Lena Jean Wiggins
• Jason Wilcox, LCSW
• Wild Flower Healthcare, LLC

• Physician Assistant in Roseburg, OR
• Providers in Roseburg, OR by specialty
• Physician Assistant in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.