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General NPI Number Information
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NPI Number | 1790134138
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Entity Type | Individual
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Provider Name | CAROLINA COLETTE DICKSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/07/2016
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Last Update Date | 08/06/2019
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Provider Practice Location Address
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Address Line | 4750 LINCOLN BLVD APT 183
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6982
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Country | US
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Telephone | 305-215-0932
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Fax |
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Provider Business Mailing Address
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Address Line | 1044 JEFFERY ST
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City | BOCA RATON
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State | FL
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Zip | 33487-4185
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 9110052
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License Number State | FL
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