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 1:2170 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7026
Mailing Address - Country:US
Mailing Address - Phone:530-541-3420
Mailing Address - Fax:
Practice Address - Street 1:155 HIGHWAY 50 STE 102
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-9816
Practice Address - Country:US
Practice Address - Phone:530-541-5497
Practice Address - Fax:530-541-8683
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65355363A00000X, 363AS0400X
NVPA1358363AS0400X, 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