Provider Demographics
NPI:1447698303
Name:HICKS, BRADLEY JAMES (PA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAMES
Last Name:HICKS
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:170 MEDICAL PARK RD
Mailing Address - Street 2:STE 102
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8541
Mailing Address - Country:US
Mailing Address - Phone:704-660-4750
Mailing Address - Fax:704-660-4751
Practice Address - Street 1:170 MEDICAL PARK RD STE 102
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8541
Practice Address - Country:US
Practice Address - Phone:704-660-4750
Practice Address - Fax:704-660-4751
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC001004289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant