Basic Information
| Provider Information | |||||||||
| NPI: | 1851476386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKIE | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 115 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207962600 | ||||||||
| FaxNumber: | 6025281296 | ||||||||
| Practice Location | |||||||||
| Address1: | 10720 E SOUTHERN AVE | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852093810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803650050 | ||||||||
| FaxNumber: | 4803650049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 31655 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 31655 | 01 | AZ | ARIZONA STATE LICENSE | OTHER |