Healthcare Provider Details

I. General information

NPI: 1447255278
Provider Name (Legal Business Name): RONALD DICKINSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 A SCURRY AVE
DAINGERFIELD TX
75638
US

IV. Provider business mailing address

PO BOX 4207
LONGVIEW TX
75606-4207
US

V. Phone/Fax

Practice location:
  • Phone: 903-645-2044
  • Fax: 903-645-2270
Mailing address:
  • Phone: 903-315-5730
  • Fax: 903-315-2907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00237
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: