Provider Demographics
NPI:1588656409
Name:HICKS, NANCE D (D0)
Entity Type:Individual
Prefix:
First Name:NANCE
Middle Name:D
Last Name:HICKS
Suffix:
Gender:F
Credentials:D0
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 PALUXY MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-7901
Mailing Address - Country:US
Mailing Address - Phone:817-408-3320
Mailing Address - Fax:817-408-3328
Practice Address - Street 1:1220 PALUXY MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-7901
Practice Address - Country:US
Practice Address - Phone:817-408-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR2620207Q00000X
OK3975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
OK248623501Medicare PIN