Provider Demographics
NPI:1134471279
Name:DICKERSON, SHAUNTUN
Entity Type:Individual
Prefix:
First Name:SHAUNTUN
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-2409
Mailing Address - Country:US
Mailing Address - Phone:414-366-6269
Mailing Address - Fax:
Practice Address - Street 1:1418 N 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-2409
Practice Address - Country:US
Practice Address - Phone:414-366-6269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-14
Last Update Date:2012-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies