Healthcare Provider Details

I. General information

NPI: 1316493687
Provider Name (Legal Business Name): WILSON HICKMAN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

2 CHINKAPIN CT
HOMOSASSA FL
34446-5224
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-4673
  • Fax:
Mailing address:
  • Phone: 412-715-8079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11012197
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11012197
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberSP016282
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: