=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548036098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAVANNAH HICKMAN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2023
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 911 S MAIN STREET
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-463-2374
-----------------------------------------------------
Fax | 352-463-2726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23476 NW 186TH AVE
-----------------------------------------------------
City | HIGH SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32643-0673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-454-0698
-----------------------------------------------------
Fax | 386-454-0690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9118908
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------