Basic Information
Provider Information | |||||||||
NPI: | 1316907959 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HICKS | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 507 | ||||||||
Address2: |   | ||||||||
City: | LOWELL | ||||||||
State: | AR | ||||||||
PostalCode: | 727450507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8164618288 | ||||||||
FaxNumber: | 8164616586 | ||||||||
Practice Location | |||||||||
Address1: | 1200 W WALNUT ST | ||||||||
Address2: |   | ||||||||
City: | ROGERS | ||||||||
State: | AR | ||||||||
PostalCode: | 727563546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4796360200 | ||||||||
FaxNumber: | 4799362912 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2006 | ||||||||
LastUpdateDate: | 12/06/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CO1400 | AR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 919212001 | 05 | MO |   | MEDICAID | 150123701 | 05 | AR |   | MEDICAID |