Basic Information
| Provider Information | |||||||||
| NPI: | 1831453109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON-HUMPHRIES | ||||||||
| FirstName: | TANIA | ||||||||
| MiddleName: | JOSEPHINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533828540 | ||||||||
| FaxNumber: | 2068704770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533828540 | ||||||||
| FaxNumber: | 2068704770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2012 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA1358 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA60970121 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA60970121 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2147925 | 05 | WA | MEDICAID |