Provider Demographics
NPI:1730183583
Name:DYER, MILDRED SUE OFFICER (PA)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:SUE OFFICER
Last Name:DYER
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 1:135 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2478
Mailing Address - Country:US
Mailing Address - Phone:931-526-2488
Mailing Address - Fax:931-526-6332
Practice Address - Street 1:135 W 3RD ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2478
Practice Address - Country:US
Practice Address - Phone:931-526-2488
Practice Address - Fax:931-526-6332
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q27855Medicare UPIN
TN3662780Medicare ID - Type UnspecifiedTN MEDICARE