Provider Demographics
NPI:1619141124
Name:DISHON, VICKI (MHS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:
Last Name:DISHON
Suffix:
Gender:F
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHS, PA-C
Mailing Address - Street 1:3702 NEW VISION DR
Mailing Address - Street 2:BLDG B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:614-777-5700
Mailing Address - Fax:614-777-5777
Practice Address - Street 1:1234 E DUPONT RD STE 3
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-672-6590
Practice Address - Fax:260-672-6599
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.001964363A00000X
IN10002438A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant