Provider Demographics
NPI:1184249146
Name:DICKSON, TAKARA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:TAKARA
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:TAKARA
Other - Middle Name:
Other - Last Name:RAGLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:1860 PENNSYLVANIA AVE CA
Mailing Address - Street 2:STE 110
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3550
Mailing Address - Country:US
Mailing Address - Phone:707-646-4414
Mailing Address - Fax:
Practice Address - Street 1:1860 PENNSYLVANIA AVE CA
Practice Address - Street 2:STE 110
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3550
Practice Address - Country:US
Practice Address - Phone:707-646-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60134363A00000X
390200000X
CAPA60134363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program