Healthcare Provider Details

I. General information

NPI: 1023170081
Provider Name (Legal Business Name): DALE DICKINSON, CRNA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 FALLS AVE W
TWIN FALLS ID
83301-3115
US

IV. Provider business mailing address

PO BOX 3245
IDAHO FALLS ID
83403-3245
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-1662
  • Fax:
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-525-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberN-17941
License Number StateID

VIII. Authorized Official

Name: DALE DICKINSON
Title or Position: PRESIDENT
Credential: CRNA
Phone: 208-525-2090