Provider Demographics
NPI:1316900624
Name:HICKS, PATTY (PA)
Entity type:Individual
Prefix:
First Name:PATTY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 SW H K DODGEN LOOP
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-1815
Mailing Address - Country:US
Mailing Address - Phone:254-778-5400
Mailing Address - Fax:254-778-5444
Practice Address - Street 1:2201 S W S YOUNG DR
Practice Address - Street 2:SUITE 111-B
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5317
Practice Address - Country:US
Practice Address - Phone:254-680-3376
Practice Address - Fax:254-680-5252
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA01873OtherTX LICENSE NUMBER
TX8J2905Medicare PIN
TXPA01873OtherTX LICENSE NUMBER