Healthcare Provider Details

I. General information

NPI: 1184214066
Provider Name (Legal Business Name): THERESA ISABELLA HICKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 HERLONG CT STE B
ROCK HILL SC
29732-1193
US

IV. Provider business mailing address

9104 BLUE RIDGE DR
FORT MILL SC
29707-2510
US

V. Phone/Fax

Practice location:
  • Phone: 704-335-9794
  • Fax:
Mailing address:
  • Phone: 919-564-6203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001011935
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: