Provider Demographics
NPI:1831522747
Name:DICKERSON, ODESSA (PA)
Entity type:Individual
Prefix:MS
First Name:ODESSA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:2811 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2724
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA61121709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant