Provider Demographics
NPI:1568562601
Name:DICKINSON, GWENDOLYN M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:M
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:GWENDOLYN
Other - Middle Name:M
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:132 AUTUMN TRL
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-1667
Mailing Address - Country:US
Mailing Address - Phone:610-857-5015
Mailing Address - Fax:
Practice Address - Street 1:1400 BLACKHORSE HILL RD
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-2040
Practice Address - Country:US
Practice Address - Phone:610-384-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000094L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical