Basic Information
| Provider Information | |||||||||
| NPI: | 1215471040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | MARKUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10300 SW EASTRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039445000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10300 SW EASTRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039445000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2016 | ||||||||
| LastUpdateDate: | 12/13/2016 | ||||||||
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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 | 106S00000X | N | 372600000X | Y | Nursing Service Related Providers | Adult Companion |
No ID Information.