Provider Demographics
NPI:1407068828
Name:DICKINSON, ROBERT BRUCE (APN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BRUCE
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:APN
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 28007
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37424-8007
Mailing Address - Country:US
Mailing Address - Phone:615-830-7078
Mailing Address - Fax:
Practice Address - Street 1:983 NISSAN DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167
Practice Address - Country:US
Practice Address - Phone:615-459-1944
Practice Address - Fax:615-459-1944
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA666869163W00000X
GARN177126163W00000X
TN131381163W00000X
FL9316562363L00000X
TN8181363L00000X, 363LA2200X
WAAP60935771363L00000X
OR201706588NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP90560Medicare UPIN