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General NPI Number Information
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NPI Number | 1003115577
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Entity Type | Organization
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Legal Business Name | STEPHEN A. HICKNER, M.D., LLC
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Dates
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Enumeration Date | 03/22/2011
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Last Update Date | 03/29/2011
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Provider Practice Location Address
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Address Line | 8160 HIGHWAY 789
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City | LANDER
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State | WY
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Zip | 82520-2953
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Country | US
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Telephone | 616-633-8628
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Fax |
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Provider Business Mailing Address
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Address Line | 8160 HIGHWAY 789
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City | LANDER
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State | WY
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Zip | 82520-2953
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Country | US
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Telephone | 616-633-8628
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Fax |
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Authorized Official
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Title or Position | REGISTERED AGENT
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Name | STEPHEN ANDREW HICKNER
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Credential | M.D.
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Telephone | 616-633-8628
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | TL1524
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License Number State | WY
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