Provider Demographics
NPI:1679724314
Name:DIXON, ADRIENNE NICOLE (JD, PA-C)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:NICOLE
Last Name:DIXON
Suffix:
Gender:F
Credentials:JD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 EASTERN AVENUE
Mailing Address - Street 2:MFL WEST, 6TH FLOOR CIMS SUITE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2747
Mailing Address - Country:US
Mailing Address - Phone:410-550-5018
Mailing Address - Fax:
Practice Address - Street 1:5200 EASTERN AVE
Practice Address - Street 2:MFL WEST, 6TH FLOOR CIMS SUITE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2734
Practice Address - Country:US
Practice Address - Phone:410-550-5018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002923363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD140110YUXMedicare PIN