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General NPI Number Information
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NPI Number | 1790246734
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Entity Type | Individual
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Provider Name | KEITH HICKMAN
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Gender | Male
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Dates
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Enumeration Date | 03/30/2019
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Last Update Date | 08/15/2023
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Provider Practice Location Address
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Address Line | 3705 EMERSON AVE
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City | PARKERSBURG
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State | WV
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Zip | 26104-1118
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Country | US
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Telephone | 304-485-7717
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Fax |
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Provider Business Mailing Address
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Address Line | 474 VALLEY MANOR LN
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City | WILLIAMSTOWN
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State | WV
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Zip | 26187-8249
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Country | US
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Telephone | 304-224-4301
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4477
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License Number State | WV
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