Healthcare Provider Details

I. General information

NPI: 1760597462
Provider Name (Legal Business Name): KAREN DICKERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1352 E CENTER ST
POCATELLO ID
83201-4734
US

IV. Provider business mailing address

PO BOX O
POCATELLO ID
83205-0049
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-2001
  • Fax: 208-232-2195
Mailing address:
  • Phone: 208-234-2001
  • Fax: 208-232-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA566
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: