Provider Demographics
NPI:1073875985
Name:LORI HICKSON, MD PA
Entity Type:Organization
Organization Name:LORI HICKSON, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:HICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-203-6695
Mailing Address - Street 1:1619 E. COMMON ST., BLDG. L
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-3464
Mailing Address - Country:US
Mailing Address - Phone:830-203-6695
Mailing Address - Fax:830-214-6292
Practice Address - Street 1:1619 E. COMMON ST., BLDG. L
Practice Address - Street 2:SUITE 1201
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130
Practice Address - Country:US
Practice Address - Phone:830-203-6695
Practice Address - Fax:830-214-6292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2259207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty