Provider Demographics
NPI:1467550616
Name:HICKS, SHANE C (IDC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:C
Last Name:HICKS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS KENTUCKY (SSBN 737)(BLUE)
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96698-2126
Mailing Address - Country:US
Mailing Address - Phone:360-315-4204
Mailing Address - Fax:360-396-4247
Practice Address - Street 1:USS KENTUCKY (SSBN 737)(BLUE)
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96698-2126
Practice Address - Country:US
Practice Address - Phone:360-315-4204
Practice Address - Fax:360-396-4247
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman