Provider Demographics
NPI:1386423531
Name:HICKERSON, KAMRI (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:KAMRI
Middle Name:
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5130
Mailing Address - Country:US
Mailing Address - Phone:903-232-8100
Mailing Address - Fax:903-232-8115
Practice Address - Street 1:805 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5130
Practice Address - Country:US
Practice Address - Phone:903-232-8100
Practice Address - Fax:903-232-8115
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant