Provider Demographics
NPI:1306120779
Name:HICKMAN, KEVIN IMMARRI (CRNA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:IMMARRI
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-6102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2612
Practice Address - Country:US
Practice Address - Phone:212-312-5258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22570531367500000X
CANA4391367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA165666Medicare PIN
CAHE403ZMedicare PIN