Provider Demographics
NPI:1699302232
Name:HICKSON, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:HICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 COLORADO AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1220
Mailing Address - Country:US
Mailing Address - Phone:952-546-5322
Mailing Address - Fax:
Practice Address - Street 1:1342 COLORADO AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1220
Practice Address - Country:US
Practice Address - Phone:952-546-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN13804363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program