Provider Demographics
NPI:1588601298
Name:HICKS, BRYAN (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-822-4355
Mailing Address - Fax:410-522-0017
Practice Address - Street 1:3500 BOSTON ST STE J1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-5723
Practice Address - Country:US
Practice Address - Phone:410-522-0001
Practice Address - Fax:410-522-0017
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDO386Medicare PIN