Provider Demographics
NPI:1184905895
Name:HICKS, MELISSA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:HICKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:MUZNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:400 ROSALIND REDFERN GROVER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701
Mailing Address - Country:US
Mailing Address - Phone:432-221-5252
Mailing Address - Fax:
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PARKWAY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701
Practice Address - Country:US
Practice Address - Phone:432-685-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 07467363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB 140918OtherMEDICARE PTAN