Basic Information
| Provider Information | |||||||||
| NPI: | 1568014561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | GARRETT | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 N 1ST ST STE 181 | ||||||||
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| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937260517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599789154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1303 E HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594503000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2019 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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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 | 363LF0000X | 95011637 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.