Basic Information
| Provider Information | |||||||||
| NPI: | 1922406297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | MYRLANDE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5380 HICKORY HOLLOW PKWY | ||||||||
| Address2: | STE 201 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370133117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158912070 | ||||||||
| FaxNumber: | 6158912056 | ||||||||
| Practice Location | |||||||||
| Address1: | 5380 HICKORY HOLLOW PKWY | ||||||||
| Address2: | STE 201 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370133117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158912070 | ||||||||
| FaxNumber: | 6158912056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2014 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9108246 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 3055 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 5200868 | 01 | FL | AETNA | OTHER | PA9108246 | 01 | FL | LICENSE NUMBER | OTHER | Y0Q74 | 01 | FL | BC/BS | OTHER | 1125636 | 01 | FL | CAREPLUS | OTHER |