Provider Demographics
NPI:1063992857
Name:DIRKSEN, KEVIN J (ARNP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:DIRKSEN
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5401
Mailing Address - Country:US
Mailing Address - Phone:319-272-8349
Mailing Address - Fax:319-272-8355
Practice Address - Street 1:3421 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5401
Practice Address - Country:US
Practice Address - Phone:757-561-4487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6124363L00000X, 363LA2100X
MN2464790363LA2100X
IAH161051363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner