Provider Demographics
NPI:1083772982
Name:VAN DYKE, CHRISTINE JANET (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:JANET
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 1:260 26TH ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-2203
Mailing Address - Country:US
Mailing Address - Phone:608-643-3311
Mailing Address - Fax:
Practice Address - Street 1:260 26TH ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2203
Practice Address - Country:US
Practice Address - Phone:608-643-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009019852363A00000X
CAPA17604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant