Basic Information
| Provider Information | |||||||||
| NPI: | 1790098150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKINSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 N MONTE VISTA ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802720922 | ||||||||
| FaxNumber: | 5802720811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 STONECIPHER DR | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748203439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804363980 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363LF0000X | 83156 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.