Provider Demographics
NPI:1639910243
Name:HICKS, RILEY JO (PA-C)
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:JO
Last Name:HICKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RILEY
Other - Middle Name:JO
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2070
Mailing Address - Country:US
Mailing Address - Phone:731-592-4255
Mailing Address - Fax:
Practice Address - Street 1:24 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2070
Practice Address - Country:US
Practice Address - Phone:731-592-4255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant