Provider Demographics
NPI:1245203421
Name:ICKES, ELIZABETH RENEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:RENEE
Last Name:ICKES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15840 MEDICAL DR S
Mailing Address - Street 2:SUITE B
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-7833
Mailing Address - Country:US
Mailing Address - Phone:419-425-3780
Mailing Address - Fax:419-425-6781
Practice Address - Street 1:15840 MEDICAL DR S
Practice Address - Street 2:SUITE B
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-7833
Practice Address - Country:US
Practice Address - Phone:419-425-3780
Practice Address - Fax:419-425-6781
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002084363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00639340OtherRAILROAD MEDICARE
OHP00863389OtherRAILROAD MEDICARE
OHQ01457Medicare UPIN
OHPA22012Medicare PIN
OHP00863389OtherRAILROAD MEDICARE