Healthcare Provider Details

I. General information

NPI: 1700647542
Provider Name (Legal Business Name): KYLE DOUGLAS HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E RIVER PARK PL W
FRESNO CA
93720-1551
US

IV. Provider business mailing address

3222 EVERGLADE AVE # A
CLOVIS CA
93619-9586
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-4950
  • Fax:
Mailing address:
  • Phone: 559-999-0660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95069170
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95069170
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: