Provider Demographics
NPI:1790206670
Name:FICKEN, TIM JOE (CSTFA)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:JOE
Last Name:FICKEN
Suffix:
Gender:M
Credentials:CSTFA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 SIOUX TRL
Mailing Address - Street 2:
Mailing Address - City:BAR NUNN
Mailing Address - State:WY
Mailing Address - Zip Code:82601-7611
Mailing Address - Country:US
Mailing Address - Phone:307-277-4209
Mailing Address - Fax:
Practice Address - Street 1:2110 SIOUX TRL
Practice Address - Street 2:
Practice Address - City:BAR NUNN
Practice Address - State:WY
Practice Address - Zip Code:82601-7611
Practice Address - Country:US
Practice Address - Phone:307-277-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical