Basic Information
Provider Information | |||||||||
NPI: | 1154373983 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DYKSTRA | ||||||||
FirstName: | TODD | ||||||||
MiddleName: | BRYAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 68 | ||||||||
Address2: |   | ||||||||
City: | POLLOCKSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285730068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526384023 | ||||||||
FaxNumber: | 2526332833 | ||||||||
Practice Location | |||||||||
Address1: | 2604 DR MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | NEW BERN | ||||||||
State: | NC | ||||||||
PostalCode: | 285624238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526384023 | ||||||||
FaxNumber: | 2526332833 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 08/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 009787-1 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | 001382 | IA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-12474 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 02970441 | 05 | NY |   | MEDICAID | 101220000005 | 01 | NY | FIDELIS | OTHER |