Provider Demographics
NPI:1376134767
Name:HICKERSON, LARRY THOMAS JR (NP-C)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:THOMAS
Last Name:HICKERSON
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0040
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:
Practice Address - Street 1:226 MEDICAL PLAZA LN
Practice Address - Street 2:
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7425
Practice Address - Country:US
Practice Address - Phone:606-633-4871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015776363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty