Provider Demographics
NPI:1730380072
Name:HICKS, KEVIN SPENCER
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SPENCER
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-397-3119
Mailing Address - Fax:360-604-1755
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-397-3119
Practice Address - Fax:360-604-1755
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60088481363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8541625Medicaid
WAG8881267Medicare PIN