Provider Demographics
NPI:1104854181
Name:DICKERSON, ALISSA RODGERS (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:RODGERS
Last Name:DICKERSON
Suffix:
Gender:F
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 1:779 CONDON DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4703
Mailing Address - Country:US
Mailing Address - Phone:843-795-6366
Mailing Address - Fax:
Practice Address - Street 1:21 GAMECOCK AVE STE E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3368
Practice Address - Country:US
Practice Address - Phone:843-763-9664
Practice Address - Fax:843-763-2949
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0337PAMedicaid
Q35877Medicare UPIN
SC0337PAMedicaid