MEDICARE: MR. KEVIN IMMARRI HICKMAN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	RN810317	PA

General Provider Information

NPI Number	:	1306120779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN IMMARRI HICKMAN CRNA

Provider Business Mailing Address
First Line	:	100 N ACADEMY AVE
Second Line	:
City	:	DANVILLE
State	:	PA
Zip	:	17822-4903
Country	:	US
Telephone Number	:	570-808-7850
Fax Number	:	570-808-7855

Provider Business Practice Location Address
First Line	:	1000 E MOUNTAIN DR
Second Line	:
City	:	WILKES BARRE
State	:	PA
Zip	:	18711-0027
Country	:	US
Telephone Number	:	570-808-7850
Fax Number	:	570-808-7855

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2011
Last Update Date	:	03/09/2026

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