Provider Demographics
NPI:1578714986
Name:HICKS, ALICIA J (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:J
Last Name:HICKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:J
Other - Last Name:BRUNNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2175 NW SHEVLIN PARK RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7101
Mailing Address - Country:US
Mailing Address - Phone:541-389-7741
Mailing Address - Fax:541-278-8375
Practice Address - Street 1:2175 NW SHEVLIN PARK RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703
Practice Address - Country:US
Practice Address - Phone:541-389-7741
Practice Address - Fax:541-278-8375
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA001137363A00000X
ORPA176350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0008104Medicare PIN