Provider Demographics
NPI:1245015338
Name:DICKERSON, NOAH (PT)
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 23RD ST APT 408
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2328
Mailing Address - Country:US
Mailing Address - Phone:530-215-6424
Mailing Address - Fax:
Practice Address - Street 1:2322 POWELL ST
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1738
Practice Address - Country:US
Practice Address - Phone:510-653-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304425208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation