Basic Information
| Provider Information | |||||||||
| NPI: | 1518030493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKINSON | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3245 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085252662 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 FALLS AVE W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087331662 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N-17941 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.