Provider Demographics
NPI:1306842307
Name:VAN DYKE, LEROY KEITH (PA)
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:KEITH
Last Name:VAN DYKE
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 1:3322 ROAD N NE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-9505
Mailing Address - Country:US
Mailing Address - Phone:509-793-9051
Mailing Address - Fax:509-766-8585
Practice Address - Street 1:3322 ROAD N NE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-9505
Practice Address - Country:US
Practice Address - Phone:509-793-9051
Practice Address - Fax:509-766-8585
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8421323Medicaid