Most Relevant Information
Provider Data
| NPI Number: | 1003285693 |
| Provider Name: | GRAYSON WICKHAM |
| Entity Type: | Individual |
| Taxonomy Code: | 225100000X |
| Specialty: | Physical Therapist |
| License Number: | 039473 |
Most Important Dates
| Enumeration Date: | 09/24/2015 |
| Last Updated: | 09/24/2015 |
Provider Practice Location
667 MADISON AVE
NEW YORK
NY
100658029
Practice Location Phone/Fax
| Phone: | 8774745280 |
| Fax: |
Provider Mailing Location
2102 81ST ST
EAST ELMHURST
NY
113701321
Provider Mailing Phone/Fax
| Phone: | |
| Fax: |