Provider Demographics
NPI:1578641627
Name:HICKS-DERIDDER, HOLLY (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:HICKS-DERIDDER
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 1:2700 HIGHWAY 34 E BLDG 300
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1330
Mailing Address - Country:US
Mailing Address - Phone:770-304-0987
Mailing Address - Fax:770-251-0938
Practice Address - Street 1:2700 HIGHWAY 34 E BLDG 300
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1330
Practice Address - Country:US
Practice Address - Phone:770-304-0987
Practice Address - Fax:770-251-0938
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003338363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002196AMedicaid
GA100002196AMedicaid
GA97WCCRBMedicare PIN