Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 4412 | AZ |
NPI | 1861499485 |
---|---|
Provider Name | Paul W Dickerson |
First Address | Mesa, AZ 85210-3028 |
Second Address | Phoenix, AZ 85050-4282 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2005 |
Last Update Date | 05/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T67104 | (02) | AZ |