Provider Demographics
NPI:1235145715
Name:DICKSON, HOLLY A (MD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:DICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 WATSON ST N STE 200
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3948
Mailing Address - Country:US
Mailing Address - Phone:360-367-2970
Mailing Address - Fax:360-998-3241
Practice Address - Street 1:853 WATSON ST N STE 200
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3948
Practice Address - Country:US
Practice Address - Phone:360-367-2970
Practice Address - Fax:360-998-3241
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040581207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8286965Medicaid
WA8935272OtherCRIME VICTIMS
WA154155OtherL & I
WA160056450OtherRAILROAD
WA160056450OtherRAILROAD
WA8935272OtherCRIME VICTIMS
WAH44935Medicare UPIN