Provider Demographics
NPI:1922406297
Name:DIXON, MYRLANDE (PA-C)
Entity Type:Individual
Prefix:
First Name:MYRLANDE
Middle Name:
Last Name:DIXON
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 1:5380 HICKORY HOLLOW PKWY
Mailing Address - Street 2:STE 201
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3117
Mailing Address - Country:US
Mailing Address - Phone:615-891-2070
Mailing Address - Fax:615-891-2056
Practice Address - Street 1:5380 HICKORY HOLLOW PKWY
Practice Address - Street 2:STE 201
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3117
Practice Address - Country:US
Practice Address - Phone:615-891-2070
Practice Address - Fax:615-891-2056
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108246363A00000X
TN3055363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5200868OtherAETNA
FLPA9108246OtherLICENSE NUMBER
FLY0Q74OtherBC/BS
FL1125636OtherCAREPLUS
FL5200868OtherAETNA