Healthcare Provider Details

I. General information

NPI: 1003042268
Provider Name (Legal Business Name): IAN EDWIN DICK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9404A MAIN ST
FAIRFAX VA
22031-4032
US

IV. Provider business mailing address

PO BOX 791775
BALTIMORE MD
21279-1775
US

V. Phone/Fax

Practice location:
  • Phone: 571-404-6974
  • Fax: 571-604-6975
Mailing address:
  • Phone: 571-302-5000
  • Fax: 571-302-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004431
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: