Healthcare Provider Details

I. General information

NPI: 1376134767
Provider Name (Legal Business Name): LARRY THOMAS HICKERSON JR. NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 MEDICAL PLAZA LN
WHITESBURG KY
41858-7425
US

IV. Provider business mailing address

PO BOX 40
WHITESBURG KY
41858-0040
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-4871
  • Fax:
Mailing address:
  • Phone: 606-633-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3015776
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: