Provider Demographics
NPI:1801839444
Name:DICKERSON, JAMES DAVIN (ARNP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DAVIN
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9045
Mailing Address - Country:US
Mailing Address - Phone:712-256-7511
Mailing Address - Fax:
Practice Address - Street 1:300 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-9045
Practice Address - Country:US
Practice Address - Phone:712-256-7511
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA108066363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP67057Medicare UPIN
NE275881Medicare ID - Type Unspecified