Basic Information
| Provider Information | |||||||||
| NPI: | 1730380072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | SPENCER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603973119 | ||||||||
| FaxNumber: | 3606041755 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603973119 | ||||||||
| FaxNumber: | 3606041755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
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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 | 363A00000X | PA60088481 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8541625 | 05 | WA | MEDICAID |