Provider Demographics
NPI:1790870897
Name:BRICKER, DEWAYNE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DEWAYNE
Middle Name:
Last Name:BRICKER
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 1:417 CREEK HOLW
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3739
Mailing Address - Country:US
Mailing Address - Phone:318-453-1879
Mailing Address - Fax:
Practice Address - Street 1:1460 E BERT KOUNS LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5644
Practice Address - Country:US
Practice Address - Phone:318-797-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 03866363A00000X
LAPA.A10376.RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant