Provider Demographics
NPI:1013261197
Name:DICUS, JAMISON (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMISON
Middle Name:
Last Name:DICUS
Suffix:
Gender:M
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 1:13300 S CLEVELAND AVE STE 56
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3871
Mailing Address - Country:US
Mailing Address - Phone:239-344-9786
Mailing Address - Fax:
Practice Address - Street 1:7370 COLLEGE PKWY STE 206
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5558
Practice Address - Country:US
Practice Address - Phone:512-730-3056
Practice Address - Fax:888-730-1925
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106955363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9106955OtherMEDICAL LICENSE