Provider Demographics
NPI:1184970048
Name:DIC, VICTORIA (PA-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:DIC
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 1:325 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-8553
Mailing Address - Country:US
Mailing Address - Phone:516-946-0064
Mailing Address - Fax:
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT002076174400000X
NY022249-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174400000XOther Service ProvidersSpecialist