Provider Demographics
NPI:1043595788
Name:HICKSON, RUBI A (NP)
Entity Type:Individual
Prefix:
First Name:RUBI
Middle Name:A
Last Name:HICKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4801
Mailing Address - Country:US
Mailing Address - Phone:707-547-5437
Mailing Address - Fax:707-547-5430
Practice Address - Street 1:1165 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4801
Practice Address - Country:US
Practice Address - Phone:707-547-5437
Practice Address - Fax:707-547-5430
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2275882363L00000X
CANP95003075363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner