Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 0101262163 | VA |
N | 208000000X | Pediatrician | 2018-02086 | NC |
N | 2080P0203X | Pediatric Critical Care Doctor | 2018-02086 | NC |
NPI | 1033539259 |
---|---|
Provider Name | Joan Vaughn Dickerson |
First Address | Charlotte, NC 28260-0447 |
Second Address | Charlotte, NC 28204-2515 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2014 |
Last Update Date | 01/02/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1033539259 | (05) | NC |
19YTW | BCBS OF NC (01) | NC |
NN5712A | MEDICARE (01) | NC |