1023163474 NPI number — STERLING C HICKSON PA-C

Table of content: STERLING C HICKSON PA-C (NPI 1023163474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023163474 NPI number — STERLING C HICKSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKSON
Provider First Name:
STERLING
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023163474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 DOVE CROSSING LN STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAVASOTA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77868-5272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-825-0000
Provider Business Mailing Address Fax Number:
936-825-8001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 DOVE CROSSING LN STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAVASOTA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77868-5272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-825-0000
Provider Business Practice Location Address Fax Number:
936-825-8001
Provider Enumeration Date:
01/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1700973187 . This is a "NPI CLINIC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45-1981 . This is a "MEDICARE-FQHC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".