Healthcare Provider Details

I. General information

NPI: 1780835033
Provider Name (Legal Business Name): THEODORE C HICKS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S REED RD
KOKOMO IN
46901-6248
US

IV. Provider business mailing address

746 N 1100 W
KEMPTON IN
46049-9787
US

V. Phone/Fax

Practice location:
  • Phone: 765-457-4370
  • Fax:
Mailing address:
  • Phone: 317-441-5347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001034A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: