Basic Information
| Provider Information | |||||||||
| NPI: | 1700840675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKERSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 92900 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036585521 | ||||||||
| FaxNumber: | 5036585002 | ||||||||
| Practice Location | |||||||||
| Address1: | 14450 SE ROYER RD | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970158730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036585521 | ||||||||
| FaxNumber: | 5036585002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 08/09/2010 | ||||||||
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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 | 207Q00000X | MD10999 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8438574 | 05 | WA | MEDICAID | 240325 | 05 | OR | MEDICAID |