Provider Demographics
NPI:1275560336
Name:HICKERSON, ERICA C (PA-C)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:C
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:CARIN
Other - Last Name:OBORNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1973
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-1973
Mailing Address - Country:US
Mailing Address - Phone:316-722-1333
Mailing Address - Fax:316-722-3058
Practice Address - Street 1:4013 N RIDGE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-8857
Practice Address - Country:US
Practice Address - Phone:316-722-1333
Practice Address - Fax:316-722-3058
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSQ51610Medicare UPIN
KS426887Medicare ID - Type Unspecified
KSKA1634006Medicare UPIN