Basic Information
| Provider Information | |||||||||
| NPI: | 1457531964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIXSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | ACA-BC-HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8800 SE SUNNYSIDE RD STE 300N | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812862999 | ||||||||
| FaxNumber: | 5126074893 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 BATTLEFIELD PKWY | ||||||||
| Address2: | |||||||||
| City: | FT OGLETHORPE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307424044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068580466 | ||||||||
| FaxNumber: | 5036595968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | GA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | 299 | TN | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237700000X | GA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 4033913 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER |