Provider Demographics
NPI:1376061911
Name:DIRICKSON, ALISANDRA MARGARET
Entity Type:Individual
Prefix:
First Name:ALISANDRA
Middle Name:MARGARET
Last Name:DIRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:GOLDTHWAITE
Mailing Address - State:TX
Mailing Address - Zip Code:76844-0188
Mailing Address - Country:US
Mailing Address - Phone:325-451-0910
Mailing Address - Fax:
Practice Address - Street 1:101 A SOUTH PARK DRIVE
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801
Practice Address - Country:US
Practice Address - Phone:325-646-6568
Practice Address - Fax:325-646-9199
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant