Provider Demographics
NPI:1487695367
Name:VAN DYKE, LESLIE IPOCK (PA-C)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:IPOCK
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 JOHN PLATT DR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4321
Mailing Address - Country:US
Mailing Address - Phone:252-247-4297
Mailing Address - Fax:252-247-1620
Practice Address - Street 1:3511 JOHN PLATT DR
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4321
Practice Address - Country:US
Practice Address - Phone:252-247-4297
Practice Address - Fax:252-247-1620
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103155363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2753020DMedicare PIN
NCP00473020Medicare PIN
NC2753020CMedicare PIN