Provider Demographics
NPI:1497026280
Name:DIXON, JEANETTE O (PA-C)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:O
Last Name:DIXON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 E 190TH ST APT 52
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-4540
Mailing Address - Country:US
Mailing Address - Phone:347-493-4920
Mailing Address - Fax:
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2508
Practice Address - Country:US
Practice Address - Phone:718-630-8718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant