Basic Information
| Provider Information | |||||||||
| NPI: | 1396873360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKENS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 LEWIS HARGETT CIR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405033590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592681030 | ||||||||
| FaxNumber: | 8592694120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 HARRODSBURG RD | ||||||||
| Address2: | BLDG D, SUITE 102 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592762525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 668A | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 74305103 | 05 | KY | MEDICAID |