Provider Demographics
NPI:1487110474
Name:DICKSON, JONATHAN DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
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 1:1444 E STEARNS ST STE 11
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4969
Mailing Address - Country:US
Mailing Address - Phone:479-718-7546
Mailing Address - Fax:479-966-4979
Practice Address - Street 1:1444 E STEARNS ST STE 11
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4969
Practice Address - Country:US
Practice Address - Phone:479-718-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13777363A00000X
ARPA-1154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant