Provider Demographics
NPI:1104261510
Name:DYKSTRA, TIMOTHY J (CRNA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9318 MONROE CT
Mailing Address - Street 2:APT 509
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-6216
Mailing Address - Country:US
Mailing Address - Phone:708-691-1332
Mailing Address - Fax:
Practice Address - Street 1:1201 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2716
Practice Address - Country:US
Practice Address - Phone:219-757-6077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28206675A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered