Individual
LARRY CHARLES HICKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
1441 FLORIDA, MODESTO, CA 95352
(209) 576-3999
Mailing address
4301 NORTHSTAR WAY, MODESTO, CA 95356-9262
(209) 342-2300
(209) 524-4240
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CD069A
GROUP PTAN
CA
01
—
OPA108440
BLUE SHIELD
CA
05
—
OPA108440
—
CA
Enumeration date
11/04/2005
Last updated
01/11/2013
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