=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184286999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANIECIA VICTORIA HICKS PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2019
-----------------------------------------------------
Last Update Date | 07/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 HAYS AVE
-----------------------------------------------------
City | STERLING
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80751-2866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-521-3223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25533 E 5TH AVE
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80018-1681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-888-6344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | PA.0005544
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------