Provider Demographics
NPI:1043741176
Name:HICKMAN, MICHAEL (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N WAGON WAY
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-6265
Mailing Address - Country:US
Mailing Address - Phone:801-885-4916
Mailing Address - Fax:
Practice Address - Street 1:255 E 300 N
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634-7738
Practice Address - Country:US
Practice Address - Phone:435-528-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6914314-4405363LF0000X
UT2017-PCA-UT0005673747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant