Provider Demographics
NPI:1881968972
Name:HICKS, JAYSON DOUGLAS (PA)
Entity type:Individual
Prefix:MR
First Name:JAYSON
Middle Name:DOUGLAS
Last Name:HICKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-1316
Mailing Address - Country:US
Mailing Address - Phone:612-801-2745
Mailing Address - Fax:
Practice Address - Street 1:113 W RIVER PKWY
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-1316
Practice Address - Country:US
Practice Address - Phone:612-801-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA954363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical