Provider Demographics
NPI:1366093031
Name:HICKS, ANTON (PA-C)
Entity type:Individual
Prefix:
First Name:ANTON
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 LUCERNE TER
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1015
Mailing Address - Country:US
Mailing Address - Phone:474-423-1039
Mailing Address - Fax:407-425-2347
Practice Address - Street 1:1012 LUCERNE TER
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1015
Practice Address - Country:US
Practice Address - Phone:474-423-1039
Practice Address - Fax:407-425-2347
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
FLPA9120518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366093031OtherN/A