Provider Demographics
NPI:1992093066
Name:DIXON, RUSSELL (PA-C)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:DIXON
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 1:1001 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-6427
Mailing Address - Country:US
Mailing Address - Phone:641-684-2402
Mailing Address - Fax:641-684-2401
Practice Address - Street 1:5950 UNIVERSITY AVE STE 105
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-7756
Practice Address - Country:US
Practice Address - Phone:515-875-9070
Practice Address - Fax:515-875-9071
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002215363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical