Provider Demographics
NPI:1003853052
Name:DICKERSON, ROBERT (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 824
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-0824
Mailing Address - Country:US
Mailing Address - Phone:478-318-0414
Mailing Address - Fax:
Practice Address - Street 1:1013 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-0824
Practice Address - Country:US
Practice Address - Phone:478-318-0414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN129618367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered