Provider Demographics
NPI:1780835033
Name:HICKS, THEODORE C (PA-C)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:C
Last Name:HICKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 N 1100 W
Mailing Address - Street 2:
Mailing Address - City:KEMPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46049-9787
Mailing Address - Country:US
Mailing Address - Phone:317-441-5347
Mailing Address - Fax:
Practice Address - Street 1:1010 S REED RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-6248
Practice Address - Country:US
Practice Address - Phone:765-457-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001034A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN809640GMedicare PIN