Healthcare Provider Details

I. General information

NPI: 1619141124
Provider Name (Legal Business Name): VICKI DISHON MHS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICKI WATSON MHS, PA-C

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 E DUPONT RD STE 3
FORT WAYNE IN
46825-1545
US

IV. Provider business mailing address

3702 NEW VISION DR BLDG B
FORT WAYNE IN
46845-1703
US

V. Phone/Fax

Practice location:
  • Phone: 260-672-6590
  • Fax: 260-672-6599
Mailing address:
  • Phone: 614-777-5700
  • Fax: 614-777-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.001964
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002438A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: