Provider Demographics
NPI:1659064251
Name:HICKMAN, TIM JOHN
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:JOHN
Last Name:HICKMAN
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:WY
Mailing Address - Zip Code:82221-0012
Mailing Address - Country:US
Mailing Address - Phone:307-277-5361
Mailing Address - Fax:
Practice Address - Street 1:124 5TH AVE
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:WY
Practice Address - Zip Code:82221-5024
Practice Address - Country:US
Practice Address - Phone:307-277-5361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator