Provider Demographics
NPI:1568218154
Name:HICKMAN, KATIE MICHEL (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MICHEL
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5925
Mailing Address - Country:US
Mailing Address - Phone:770-237-3475
Mailing Address - Fax:
Practice Address - Street 1:1900 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5925
Practice Address - Country:US
Practice Address - Phone:770-237-3475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant