Provider Demographics
NPI:1386067304
Name:DYKES, VIRGUST JUSTICE (PA)
Entity type:Individual
Prefix:MR
First Name:VIRGUST
Middle Name:JUSTICE
Last Name:DYKES
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 1:2600 FM 1764 RD
Mailing Address - Street 2:STE 190
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-2826
Mailing Address - Country:US
Mailing Address - Phone:281-886-8964
Mailing Address - Fax:
Practice Address - Street 1:668 W BRAZOS AVE
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:TX
Practice Address - Zip Code:77486-2616
Practice Address - Country:US
Practice Address - Phone:979-345-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08778363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical