Provider Demographics
NPI:1942297197
Name:DICKEN, SARA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:MARIE
Last Name:DICKEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SARA
Other - Middle Name:MARIE
Other - Last Name:NYQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6650 EASTGATE BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37090-6018
Mailing Address - Country:US
Mailing Address - Phone:615-900-5451
Mailing Address - Fax:615-900-5440
Practice Address - Street 1:6650 EASTGATE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-6018
Practice Address - Country:US
Practice Address - Phone:615-453-9492
Practice Address - Fax:615-453-9498
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA2842363AM0700X, 363AM0700X
IA001496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031810Medicaid
ILK17623Medicare ID - Type Unspecified