1922406297 NPI number — MYRLANDE DIXON PA-C

Table of content: MYRLANDE DIXON PA-C (NPI 1922406297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922406297 NPI number — MYRLANDE DIXON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIXON
Provider First Name:
MYRLANDE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922406297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5380 HICKORY HOLLOW PKWY
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
ANTIOCH
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37013-3117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-891-2070
Provider Business Mailing Address Fax Number:
615-891-2056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5380 HICKORY HOLLOW PKWY
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
ANTIOCH
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37013-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-891-2070
Provider Business Practice Location Address Fax Number:
615-891-2056
Provider Enumeration Date:
12/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9108246 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 3055 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5200868 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PA9108246 . This is a "LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y0Q74 . This is a "BC/BS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1125636 . This is a "CAREPLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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