Provider Demographics
NPI:1760597462
Name:DICKERSON, KAREN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:DICKERSON
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:PO BOX O
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-0049
Mailing Address - Country:US
Mailing Address - Phone:208-234-2001
Mailing Address - Fax:208-232-2195
Practice Address - Street 1:1352 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4734
Practice Address - Country:US
Practice Address - Phone:208-234-2001
Practice Address - Fax:208-232-2195
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA566363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8073207000Medicaid
ID1667215Medicare ID - Type UnspecifiedCIGNA MEDICARE
ID8073207000Medicaid