Basic Information
| Provider Information | |||||||||
| NPI: | 1518053511 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BICKER | ||||||||
| FirstName: | MICAH | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4555 N WILLIAMS AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972172955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713734165 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 535 NE 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | ESTACADA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970239312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036308550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | 0325344 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA175642 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | R188820 | 01 | OR | MEDICARE PTAN | OTHER | 100427720B | 05 | KS | MEDICAID | 1518053511 | 05 | WA | MEDICAID | 500710332 | 05 | OR | MEDICAID |