Basic Information
| Provider Information | |||||||||
| NPI: | 1083786180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 515 | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255040515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047366126 | ||||||||
| FaxNumber: | 3047361531 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045261031 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 09/23/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 54468 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 08320 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 001721151 | 01 | WV | WV BLUE CROSS PROVIDER # | OTHER | 3810001843 | 05 | WV | MEDICAID | 550696369-00 | 01 | WV | WV WORKERS COMP | OTHER |