Provider Demographics
NPI:1558701292
Name:DICKERSON, CHARLES EARL JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EARL
Last Name:DICKERSON
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:640 WILMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4209
Mailing Address - Country:US
Mailing Address - Phone:301-908-8904
Mailing Address - Fax:
Practice Address - Street 1:2005 KNIGHT LANE BLDG H
Practice Address - Street 2:NAVMEDSUPCOM ATTN: MED STAFF SERVICES
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:619-532-6684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA840135163W00000X
CA4405367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse