Provider Demographics
NPI:1972550192
Name:HICKENLOOPER, COLIN R (PA-C)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:R
Last Name:HICKENLOOPER
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 1:900 N SWITZER CANYON DR APT 103
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4830
Mailing Address - Country:US
Mailing Address - Phone:907-538-6776
Mailing Address - Fax:520-244-0089
Practice Address - Street 1:823 N SAN FRANCISCO ST STE A
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3265
Practice Address - Country:US
Practice Address - Phone:520-244-0089
Practice Address - Fax:520-244-0089
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT100369363A00000X
AKPADA547363AM0700X
AZ9219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020179Medicaid
AK1020179Medicaid