Provider Demographics
NPI:1205085529
Name:DIXON, ANNIE MARIE (PA)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:MARIE
Last Name:DIXON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:MARIE
Other - Last Name:KUNZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2240 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-233-8344
Mailing Address - Fax:
Practice Address - Street 1:2240 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-233-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-761363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical