MEDICARE: MS. MYAH ELISHA HICKS-WIGGINS PA-C

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	363AM0700X	Medical Physician Assistant	001010337	NC
2	363A00000X	Physician Assistant	0010-10337	NC

General Provider Information

NPI Number	:	1861000150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MYAH ELISHA HICKS-WIGGINS PA-C

Provider Business Mailing Address
First Line	:	5317 SUMMIT HEIGHTS DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-4480
Country	:	US
Telephone Number	:	571-345-8664
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 LYNDHURST AVE
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-4026
Country	:	US
Telephone Number	:	336-765-0383
Fax Number	:	336-768-1737

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

Provider Enumeration Date	:	07/22/2020
Last Update Date	:	01/09/2025

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