Provider Demographics
NPI:1386840841
Name:HICHKAD, LISA (NCCPA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HICHKAD
Suffix:
Gender:F
Credentials:NCCPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 DEER RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5713
Mailing Address - Country:US
Mailing Address - Phone:478-476-9174
Mailing Address - Fax:
Practice Address - Street 1:210 MERCER JCT
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4016
Practice Address - Country:US
Practice Address - Phone:478-471-8593
Practice Address - Fax:478-471-8599
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant