Provider Demographics
NPI:1831453109
Name:DICKSON-HUMPHRIES, TANIA JOSEPHINE (PA-C)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:JOSEPHINE
Last Name:DICKSON-HUMPHRIES
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 1:1802 YAKIMA AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5304
Mailing Address - Country:US
Mailing Address - Phone:253-382-8540
Mailing Address - Fax:206-870-4770
Practice Address - Street 1:1802 YAKIMA AVE STE 204
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5304
Practice Address - Country:US
Practice Address - Phone:253-382-8540
Practice Address - Fax:206-870-4770
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1358363AS0400X
WAPA60970121363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2147925Medicaid