Healthcare Provider Details

I. General information

NPI: 1588174965
Provider Name (Legal Business Name): GRETCHEN DIXON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRETCHEN BAISDEN

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 MEDINA RD STE 310
MEDINA OH
44256-9312
US

IV. Provider business mailing address

3780 MEDINA RD STE 310
MEDINA OH
44256-9312
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-8441
  • Fax: 330-725-8442
Mailing address:
  • Phone: 330-725-8441
  • Fax: 330-725-8442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005191RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: