Provider Demographics
NPI:1144737917
Name:HICKMAN, CLINT M
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:M
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 N CAUSEWAY BLVD STE 625
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-1771
Mailing Address - Country:US
Mailing Address - Phone:504-262-9033
Mailing Address - Fax:504-779-5568
Practice Address - Street 1:4200 HOUMA BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2970
Practice Address - Country:US
Practice Address - Phone:800-516-5315
Practice Address - Fax:517-787-7365
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA117257367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered