Provider Demographics
NPI:1104867258
Name:RICKS, KEVIN MARK (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MARK
Last Name:RICKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 INDUSTRIAL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7055
Mailing Address - Country:US
Mailing Address - Phone:985-868-9300
Mailing Address - Fax:985-851-0053
Practice Address - Street 1:1990 INDUSTRIAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-868-9300
Practice Address - Fax:985-851-0053
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10312RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1626759Medicaid
LAS67381Medicare UPIN
LA5Y804P183Medicare PIN
LA1626759Medicaid