Basic Information
| Provider Information | |||||||||
| NPI: | 1770846131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKEL | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | RENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 196276 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995196276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072126522 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 E 36TH AVE | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075629229 | ||||||||
| FaxNumber: | 9075621603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6516 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD1603 | 05 | AK | MEDICAID |