Provider Demographics
NPI:1427531771
Name:DICKSON, KURTIS ANTONIO (PA-C)
Entity type:Individual
Prefix:
First Name:KURTIS
Middle Name:ANTONIO
Last Name:DICKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 NW PEACOCK BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2222
Mailing Address - Country:US
Mailing Address - Phone:772-204-8870
Mailing Address - Fax:772-204-8873
Practice Address - Street 1:293 NW PEACOCK BLVD STE 201
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2222
Practice Address - Country:US
Practice Address - Phone:772-204-8870
Practice Address - Fax:772-204-8873
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9111705363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant