Healthcare Provider Details

I. General information

NPI: 1699193979
Provider Name (Legal Business Name): TYSON HICKLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 HOSPITAL PL
SOLDOTNA AK
99669-7559
US

IV. Provider business mailing address

5955 ZEAMER AVE # 673MDG
JBER AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4502
  • Fax: 907-714-4696
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0116028145
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD61440052
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: