Provider Demographics
NPI:1639156573
Name:RICKS, DERON J (PA)
Entity Type:Individual
Prefix:
First Name:DERON
Middle Name:J
Last Name:RICKS
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:PO BOX 1647
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-1647
Mailing Address - Country:US
Mailing Address - Phone:208-535-4130
Mailing Address - Fax:208-535-4125
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:STE 115
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-1647
Practice Address - Country:US
Practice Address - Phone:208-535-4130
Practice Address - Fax:208-535-4125
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA555OtherBLUE CROSS
ID1666024Medicare ID - Type Unspecified
P05069Medicare UPIN