Provider Demographics
NPI:1699193979
Name:HICKLE, TYSON (MD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:HICKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 ZEAMER AVE # 673MDG
Mailing Address - Street 2:
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 HOSPITAL PL
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7559
Practice Address - Country:US
Practice Address - Phone:907-714-4502
Practice Address - Fax:907-714-4696
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116028145207P00000X
WAMD61440052207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1699522Medicaid