Provider Demographics
NPI:1780165217
Name:ICENHOUR, ALICIA WINTERS (PA-C)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:WINTERS
Last Name:ICENHOUR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:MARIE
Other - Last Name:WINTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:915 TATE BLVD SE STE 170
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-4012
Mailing Address - Country:US
Mailing Address - Phone:828-345-0800
Mailing Address - Fax:
Practice Address - Street 1:915 TATE BLVD SE STE 170
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4012
Practice Address - Country:US
Practice Address - Phone:828-345-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant