Provider Demographics
NPI:1316493687
Name:HICKMAN, WILSON (CRNP)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:997 N. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301
Mailing Address - Country:US
Mailing Address - Phone:724-222-2577
Mailing Address - Fax:
Practice Address - Street 1:95 LEONARD AVENUE
Practice Address - Street 2:BUILDING 2, 4TH FLOOR
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301
Practice Address - Country:US
Practice Address - Phone:724-223-3673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016282363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine