Provider Demographics
NPI:1073295564
Name:DICKINSON, JEREMY CHRISTIAN (PA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:CHRISTIAN
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 PORTLAND AVE STE 309
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3008
Mailing Address - Country:US
Mailing Address - Phone:585-342-2638
Mailing Address - Fax:
Practice Address - Street 1:8351 AZIMUTH DR
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-6206
Practice Address - Country:US
Practice Address - Phone:315-415-9613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical