Provider Demographics
NPI:1174161210
Name:DIKMAN, PERI MICHELLE
Entity type:Individual
Prefix:
First Name:PERI
Middle Name:MICHELLE
Last Name:DIKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E 35TH ST APT 6RW
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4124
Mailing Address - Country:US
Mailing Address - Phone:516-491-1588
Mailing Address - Fax:
Practice Address - Street 1:145 E 35TH ST APT 6RW
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4124
Practice Address - Country:US
Practice Address - Phone:516-491-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-19
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY027124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program