Basic Information
Provider Information | |||||||||
NPI: | 1609968304 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DICKINSON | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DICKINSON | ||||||||
OtherFirstName: | BILL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 909 N BROADWAY | ||||||||
Address2: | PBO | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253170699 | ||||||||
FaxNumber: | 4253170291 | ||||||||
Practice Location | |||||||||
Address1: | 916 PACIFIC AVE | ||||||||
Address2: | FIRST FLOOR | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982014147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252587390 | ||||||||
FaxNumber: | 4252587379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2006 | ||||||||
LastUpdateDate: | 05/29/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | OP00001228 | WA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 8144438 | 05 | WA |   | MEDICAID |