Basic Information
| Provider Information | |||||||||
| NPI: | 1528155009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 YORK ST - CB2041 | ||||||||
| Address2: | MILL HILL MEDICAL CONSULTANTS, INC | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884748 | ||||||||
| FaxNumber: | 2036884740 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 YORK ST - CB2041 | ||||||||
| Address2: | MILL HILL MEDICAL CONSLUTANTS, INC | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884748 | ||||||||
| FaxNumber: | 2036884740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 04/26/2010 | ||||||||
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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 | 001765 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 001765 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 001765 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.