Provider Demographics
NPI:1861000150
Name:HICKS, MYAH ELISHA
Entity Type:Individual
Prefix:MS
First Name:MYAH
Middle Name:ELISHA
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5317 SUMMIT HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4480
Mailing Address - Country:US
Mailing Address - Phone:571-345-8664
Mailing Address - Fax:
Practice Address - Street 1:3001 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4026
Practice Address - Country:US
Practice Address - Phone:336-765-0383
Practice Address - Fax:336-768-1737
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001010337363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical