Provider Demographics
NPI:1154373983
Name:DYKSTRA, TODD BRYAN (PA)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:BRYAN
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-638-4023
Mailing Address - Fax:252-633-2833
Practice Address - Street 1:2604 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-4238
Practice Address - Country:US
Practice Address - Phone:252-638-4023
Practice Address - Fax:252-633-2833
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009787-1363A00000X
IA001382363AM0700X
NC0010-12474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02970441Medicaid
NY101220000005OtherFIDELIS
NYJ4000142128Medicare PIN
NY101220000005OtherFIDELIS
IAI17527Medicare PIN
NYJ4000142131Medicare PIN