Provider Demographics
NPI:1568453801
Name:HICKS, LARRY CHARLES (PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CHARLES
Last Name:HICKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:1441 FLORIDA
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95352
Practice Address - Country:US
Practice Address - Phone:209-576-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD069AOtherGROUP PTAN
CAOPA108440OtherBLUE SHIELD
CAOPA108440Medicaid
P27573Medicare UPIN
CAOPA108440OtherBLUE SHIELD
CAOPA108440Medicaid