Provider Demographics
NPI:1275990418
Name:DICKERSON, NATHANIEL (CRNA, DNPA)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:CRNA, DNPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 E MAPLEWOOD AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-4727
Mailing Address - Country:US
Mailing Address - Phone:817-948-1637
Mailing Address - Fax:
Practice Address - Street 1:8000 E MAPLEWOOD AVE
Practice Address - Street 2:STE 200
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-4727
Practice Address - Country:US
Practice Address - Phone:303-438-3999
Practice Address - Fax:720-439-9500
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0000469367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered