Provider Demographics
NPI:1437798816
Name:DICKERSON, ANDRE ANTHONY
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:ANTHONY
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 1:8389 CLIMAX RD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:VA
Mailing Address - Zip Code:24557-2567
Mailing Address - Country:US
Mailing Address - Phone:434-238-0010
Mailing Address - Fax:434-656-8009
Practice Address - Street 1:8389 CLIMAX RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:VA
Practice Address - Zip Code:24557-2567
Practice Address - Country:US
Practice Address - Phone:434-238-0010
Practice Address - Fax:434-656-8009
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60712212347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle