Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | DC 007056-L | PA |
N | 111NX0100X | Occupational Health | DC 007056-L | PA |
NPI | 1376683094 |
---|---|
Provider Name | Dr. Tyson Lee Dixon |
First Address | Lock Haven, PA 17745-3742 |
Second Address | Lock Haven, PA 17745-3742 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2007 |
Last Update Date | 25/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001705879-0003 | (05) | PA |
977051 | BCBS OF PA (01) | PA |
U73027 | (02) | PA |