Provider Demographics
NPI:1760726699
Name:HICKS, RANDALL S (FNP-C)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:S
Last Name:HICKS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 S PATRICK DR
Mailing Address - Street 2:
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925-3606
Mailing Address - Country:US
Mailing Address - Phone:321-494-8423
Mailing Address - Fax:321-494-8334
Practice Address - Street 1:1381 S PATRICK DR
Practice Address - Street 2:
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3606
Practice Address - Country:US
Practice Address - Phone:321-494-8423
Practice Address - Fax:321-494-8334
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111716363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily