1316900624 NPI number — PATTY HICKS PA

Table of content: PATTY HICKS PA (NPI 1316900624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316900624 NPI number — PATTY HICKS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKS
Provider First Name:
PATTY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1316900624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1809 SW H K DODGEN LOOP
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76502-1815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-778-5400
Provider Business Mailing Address Fax Number:
254-778-5444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2201 S W S YOUNG DR
Provider Second Line Business Practice Location Address:
SUITE 111-B
Provider Business Practice Location Address City Name:
KILLEEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76543-5317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-680-3376
Provider Business Practice Location Address Fax Number:
254-680-5252
Provider Enumeration Date:
04/08/2006

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 , with the licence number:  PA01873 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA01873 . This is a "TX LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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