Basic Information
| Provider Information | |||||||||
| NPI: | 1457383119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKMAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2331 PROGRESS ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | WEST BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486619384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893451184 | ||||||||
| FaxNumber: | 9893456944 | ||||||||
| Practice Location | |||||||||
| Address1: | 2331 PROGRESS ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | WEST BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486619384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893451184 | ||||||||
| FaxNumber: | 9893456944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 01/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704082187 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 4747184 | 05 | MI | MEDICAID | 4747193 | 05 | MI | MEDICAID | 5008768480 | 01 | MI | BCBS PIN | OTHER | 700G210140 | 01 | MI | BCBS GROUP | OTHER |