Provider Demographics
NPI:1619729902
Name:HICKS, DONNIE WADE
Entity Type:Individual
Prefix:
First Name:DONNIE
Middle Name:WADE
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 NE 11TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-2605
Mailing Address - Country:US
Mailing Address - Phone:405-230-1136
Mailing Address - Fax:405-424-1198
Practice Address - Street 1:1501 NE 11TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-2605
Practice Address - Country:US
Practice Address - Phone:405-230-1136
Practice Address - Fax:405-424-1198
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist