Provider Demographics
NPI:1184214066
Name:HICKS, THERESA ISABELLA (PA-C)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ISABELLA
Last Name:HICKS
Suffix:
Gender:F
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 1:9104 BLUE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-2510
Mailing Address - Country:US
Mailing Address - Phone:919-564-6203
Mailing Address - Fax:
Practice Address - Street 1:1665 HERLONG CT STE B
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1193
Practice Address - Country:US
Practice Address - Phone:704-335-9794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001011935363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty