Provider Demographics
NPI:1679951933
Name:DICKENS, CARLY DAWN (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:DAWN
Last Name:DICKENS
Suffix:
Gender:F
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 1:3651 COLLEGE BLVD STE 100B
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1910
Mailing Address - Country:US
Mailing Address - Phone:913-362-0031
Mailing Address - Fax:913-319-7662
Practice Address - Street 1:3651 COLLEGE BLVD STE 100B
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1910
Practice Address - Country:US
Practice Address - Phone:913-362-0031
Practice Address - Fax:913-319-7662
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01862363A00000X
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant