Healthcare Provider Details

I. General information

NPI: 1467550616
Provider Name (Legal Business Name): SHANE C HICKS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS KENTUCKY (SSBN 737)(BLUE)
FPO AP
96698-2126
US

IV. Provider business mailing address

USS KENTUCKY (SSBN 737)(BLUE)
FPO AP
96698-2126
US

V. Phone/Fax

Practice location:
  • Phone: 360-315-4204
  • Fax: 360-396-4247
Mailing address:
  • Phone: 360-315-4204
  • Fax: 360-396-4247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: