Provider Demographics
NPI:1548432073
Name:DICKSON, WHITNEY LONG (PA)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:LONG
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:LONG
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193555301Medicaid
TXP00990933OtherRR MEDICARE
8Y5092OtherBLUE CROSS BLUE SHIELD
8Y5092OtherBLUE CROSS BLUE SHIELD