Provider Demographics
NPI:1336129451
Name:HICKS, STANLEY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:MICHAEL
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LINCOLN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1057
Mailing Address - Country:US
Mailing Address - Phone:360-425-5131
Mailing Address - Fax:
Practice Address - Street 1:700 LINCOLN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1057
Practice Address - Country:US
Practice Address - Phone:360-425-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000295382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8136988Medicaid
OR040803OtherOREGON DSHS
WA34871OtherLABOR & INDUSTRIES
WA745510Medicare ID - Type UnspecifiedMEDICARE NUMBER
WA34871OtherLABOR & INDUSTRIES