Provider Demographics
NPI:1538146766
Name:DIZON, REYNALDO DANTES (PA)
Entity type:Individual
Prefix:MR
First Name:REYNALDO
Middle Name:DANTES
Last Name:DIZON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JOEL
Other - Middle Name:DANTES
Other - Last Name:DIZON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:ONE MEDICAL CENTER DR
Mailing Address - Street 2:DHMC DEPARTMENT OF ORTHOPAEDICS
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DR
Practice Address - Street 2:DHMC DEPARTMENT OF ORTHOPAEDICS
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0903363A00000X
WAPA10004702363AM0700X
WI2551-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8860063Medicare PIN