Provider Demographics
NPI:1003042268
Name:DICK, IAN EDWIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:EDWIN
Last Name:DICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E SIX FORKS RD
Mailing Address - Street 2:#532
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1818
Mailing Address - Country:US
Mailing Address - Phone:614-783-4186
Mailing Address - Fax:
Practice Address - Street 1:900 E SIX FORKS RD
Practice Address - Street 2:#532
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1818
Practice Address - Country:US
Practice Address - Phone:614-783-4186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant