Provider Demographics
NPI:1699300087
Name:DYKSTRA, CARLEY JOHNAH (PA-C)
Entity type:Individual
Prefix:
First Name:CARLEY
Middle Name:JOHNAH
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLEY
Other - Middle Name:JOHNAH
Other - Last Name:SEROWOKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 APPLEGATE LN APT C
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3225
Mailing Address - Country:US
Mailing Address - Phone:248-904-5173
Mailing Address - Fax:
Practice Address - Street 1:9556 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-1313
Practice Address - Country:US
Practice Address - Phone:314-961-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020000655363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant