=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437156130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN BRYAN HICKS PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2005
-----------------------------------------------------
Last Update Date | 11/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 S MAIN ST 114
-----------------------------------------------------
City | BOERNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78006-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-816-6844
-----------------------------------------------------
Fax | 830-816-6922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 S MAIN ST 114
-----------------------------------------------------
City | BOERNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78006-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-816-6844
-----------------------------------------------------
Fax | 830-816-6922
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA00853
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------