Provider Demographics
NPI:1952028896
Name:DICKSON, MARY KATHRYN (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:DICKSON
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 1:1017 LIGHTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-8590
Mailing Address - Country:US
Mailing Address - Phone:803-606-5072
Mailing Address - Fax:
Practice Address - Street 1:104 ELLETT RD
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8604
Practice Address - Country:US
Practice Address - Phone:803-941-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4657OtherSOUTH CAROLINA PHYSICIAN ASSISTANT LICENSE NUMBER