Provider Demographics
NPI:1013005990
Name:HICKS, RANDY SCOTT (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:SCOTT
Last Name:HICKS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7405 N CEDAR AVE
Mailing Address - Street 2:103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3838
Mailing Address - Country:US
Mailing Address - Phone:559-261-4100
Mailing Address - Fax:559-261-4100
Practice Address - Street 1:7405 N CEDAR AVE
Practice Address - Street 2:103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3838
Practice Address - Country:US
Practice Address - Phone:559-261-4100
Practice Address - Fax:559-261-4101
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA-PT29992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA6172OtherMEDICARE RAILROAD GROUP #
CAP00459387OtherMEDICARE RAILROAD IND. #
CA0PT299920OtherBLUE SHIELD
CAZZZ25912ZMedicare PIN
CAP00459387OtherMEDICARE RAILROAD IND. #