Provider Demographics
NPI:1619149721
Name:HICKS, CHARLES P (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:HICKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 530
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5000
Mailing Address - Country:US
Mailing Address - Phone:404-257-1415
Mailing Address - Fax:404-851-1649
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:770-794-3108
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN157151367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered