Basic Information
| Provider Information | |||||||||
| NPI: | 1053891168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIRKSEN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193001129 | ||||||||
| FaxNumber: | 4193949575 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 PRO DR STE D2 | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458223307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195866480 | ||||||||
| FaxNumber: | 4195868574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2018 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.023488 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0105065 | 01 | OH | GROUP MEDICAID - JTDM FAMILY PRACTICE, LLC | OTHER | 0313733 | 05 | OH | MEDICAID | 9934723 | 01 | OH | GROUP PTAN - JTDM FAMILY PRACTICE, LLC | OTHER | H674260 | 01 | OH | MEDICARE | OTHER |