Provider Demographics
NPI:1245514264
Name:HICKS, AMANDA C (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:HICKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5812 OAK CREEK CT
Mailing Address - Street 2:
Mailing Address - City:LIPAN
Mailing Address - State:TX
Mailing Address - Zip Code:76462-6861
Mailing Address - Country:US
Mailing Address - Phone:830-385-6618
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:MAIL ROUTE MN 008-B213
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:830-385-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP121105363LF0000X
TX754875363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB142237Medicare PIN
TXTXB142236Medicare PIN
TXTXB142235Medicare PIN