Healthcare Provider Details

I. General information

NPI: 1972793966
Provider Name (Legal Business Name): ALTON AARON DICKSON P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 N. BUTLER, SUITE 2000 AND GUARDIAN ANGEL
FARMINGTON NM
87401
US

IV. Provider business mailing address

P.O. BOX # 15012
FARMINGTON NM
87401
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-9002
  • Fax:
Mailing address:
  • Phone: 505-564-9002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0530
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: