Provider Demographics
NPI:1407859341
Name:HICKS, PAULA ANN (MD)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:ANN
Last Name:HICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-0819
Mailing Address - Country:US
Mailing Address - Phone:605-665-9638
Mailing Address - Fax:605-665-0526
Practice Address - Street 1:415 W 3RD ST
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-4201
Practice Address - Country:US
Practice Address - Phone:605-665-9638
Practice Address - Fax:605-665-0526
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3820207W00000X
NE19498207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE22053OtherNE BLUE SHIELD
SD36-3050195-13Medicaid
NENA1114001OtherNE MEDICARE PTAN NORFOLK, NE
NE36-3050195-14Medicaid
SD3820OtherDAKOTACARE PROVIDER ID
SD6300100Medicaid
SD0003388OtherSD WELLMARK BLUE SHIELD
NENA1115001OtherNE MEDICARE PTAN WAYNE, NE
NE264551Medicare ID - Type UnspecifiedNE MEDICARE PROVIDER ID
SD36-3050195-13Medicaid
SD0003388OtherSD WELLMARK BLUE SHIELD
NENA1114001OtherNE MEDICARE PTAN NORFOLK, NE
NENA1115001Medicare PIN