Provider Demographics
NPI:1568425973
Name:HICKSON, PAIGE JENNIFER (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:PAIGE
Middle Name:JENNIFER
Last Name:HICKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:CHAPMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6100 NEWPORT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9235
Mailing Address - Country:US
Mailing Address - Phone:269-343-4679
Mailing Address - Fax:269-343-5929
Practice Address - Street 1:6100 NEWPORT ROAD, SUITE 100
Practice Address - Street 2:KALAMAZOO DERMATOLOGY, P.C.
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9235
Practice Address - Country:US
Practice Address - Phone:269-343-4679
Practice Address - Fax:269-343-5929
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004610363AM0700X
MI363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0C96019010Medicare PIN