Doctor Name: | MR. JASON T HICKS |
NPI Number: | 1215931720 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PCC |
License Number: | 5601003956 |
Business Practice Address: | 419 S Coral St Kalkaska, MI - 496462503 |
Business Phone Number: | 2312587500 |
Business Fax Number: | 2312587527 |
Mailing Address: | 419 S Coral St, KALKASKA |
State: | MI |
Postal Code: | 496462503 |
Phone Number: | 2312587500 |
Fax Number: | 2312587527 |
NPI Enumeration Date: | 06/13/2005 |
NPI Last Update Date: | 10/22/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363AM0700X |
License Number: | 5601003956 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MI |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Physician Assistant |
Taxonomy Specialization: | Medical |
Taxonomy Definition: |