Provider Demographics
NPI:1518033612
Name:DICKERSON, RICHARD TIMOTHY JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:TIMOTHY
Last Name:DICKERSON
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W 15TH ST
Mailing Address - Street 2:SWMC - ANESTHESIA
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2455
Mailing Address - Country:US
Mailing Address - Phone:620-629-6682
Mailing Address - Fax:
Practice Address - Street 1:315 W 15TH ST
Practice Address - Street 2:SWMC - ANESTHESIA
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-629-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-08001367500000X
KS55580367500000X
CO199844367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL999999Medicaid
AL999999Medicaid
AL9999999Medicare UPIN