Provider Demographics
NPI:1518511823
Name:HICKS, LAURA ASHLEY (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ASHLEY
Last Name:HICKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 VEGA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-5803
Mailing Address - Country:US
Mailing Address - Phone:844-736-3395
Mailing Address - Fax:
Practice Address - Street 1:5901 VEGA AVE STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-5803
Practice Address - Country:US
Practice Address - Phone:844-736-3395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant