Provider Demographics
NPI:1952605370
Name:HICKS, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:UT
Mailing Address - Zip Code:84713-1690
Mailing Address - Country:US
Mailing Address - Phone:435-438-7280
Mailing Address - Fax:435-438-7210
Practice Address - Street 1:1059 N 100 W
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:UT
Practice Address - Zip Code:84713-1690
Practice Address - Country:US
Practice Address - Phone:435-438-7280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-28
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1096261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$OtherSOCIAL SECURITY