Provider Demographics
NPI:1558365825
Name:DICKS, CLARICE Y (PA- C)
Entity Type:Individual
Prefix:MS
First Name:CLARICE
Middle Name:Y
Last Name:DICKS
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 1:2161 LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-7952
Mailing Address - Country:US
Mailing Address - Phone:859-626-7794
Mailing Address - Fax:859-626-4420
Practice Address - Street 1:2161 LEXINGTON RD
Practice Address - Street 2:1ST FLOOR, SUITE 5
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-7952
Practice Address - Country:US
Practice Address - Phone:859-626-7794
Practice Address - Fax:859-626-4420
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY183935OtherGROUP MEDICARE
KY95901005Medicaid
KY35001775OtherGROUP MEDICAID
KY35001775OtherGROUP MEDICAID
KYP14065Medicare Oscar/Certification