Provider Demographics
NPI:1356570634
Name:DICKERSON, TRACY (PA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 DORCESTER AVE
Mailing Address - Street 2:DEPT. OF SURGERY
Mailing Address - City:DORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124
Mailing Address - Country:US
Mailing Address - Phone:617-296-4000
Mailing Address - Fax:
Practice Address - Street 1:2100 DORCHESTER AVE
Practice Address - Street 2:DEPT. OF SURGERY
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5615
Practice Address - Country:US
Practice Address - Phone:617-296-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant