Basic Information
| Provider Information | |||||||||
| NPI: | 1104261510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYKSTRA | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9318 MONROE CT | ||||||||
| Address2: | APT 509 | ||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463076216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086911332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463072716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197576077 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2013 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 28206675A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.