Provider Demographics
NPI:1881632453
Name:DIMMICK, MEGAN LEX (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEX
Last Name:DIMMICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 LAKEHURST RD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755
Mailing Address - Country:US
Mailing Address - Phone:732-341-0515
Mailing Address - Fax:732-505-6006
Practice Address - Street 1:453 LAKEHURST RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755
Practice Address - Country:US
Practice Address - Phone:732-341-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00097300363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP78939Medicare UPIN
NJ089832BC1Medicare ID - Type Unspecified