Provider Demographics
NPI:1851396147
Name:HICKSON, ANN M (OD, MS)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:HICKSON
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:M
Other - Last Name:HULSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1719 TOWER DR W
Mailing Address - Street 2:STE 100
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7512
Mailing Address - Country:US
Mailing Address - Phone:651-275-3000
Mailing Address - Fax:651-275-3027
Practice Address - Street 1:237 RADIO DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4478
Practice Address - Country:US
Practice Address - Phone:651-275-3000
Practice Address - Fax:651-275-3027
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2904152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00125285OtherRAILROAD MEDICARE
MN248600800Medicaid
MN410002025Medicare PIN
MNP00125285OtherRAILROAD MEDICARE