Provider Demographics
NPI:1700344488
Name:TICE, GREGORY KEITH (NP-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:KEITH
Last Name:TICE
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL CARE WAY
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-7013
Mailing Address - Country:US
Mailing Address - Phone:334-305-2800
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL CARE WAY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-7013
Practice Address - Country:US
Practice Address - Phone:334-305-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-074520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily