Provider Demographics
NPI:1831750983
Name:HICKS, COURTNEY BRYANNE (PA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BRYANNE
Last Name:HICKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 HICKORY WOODS DR NE APT 122
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-6362
Mailing Address - Country:US
Mailing Address - Phone:304-910-6348
Mailing Address - Fax:
Practice Address - Street 1:3006 HICKORY WOODS DR NE APT 122
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-6362
Practice Address - Country:US
Practice Address - Phone:304-910-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant