Provider Demographics
NPI:1407196561
Name:DYKSTRA, JOAN LORRAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:LORRAINE
Last Name:DYKSTRA
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 1:76 CARDINAL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-9834
Mailing Address - Country:US
Mailing Address - Phone:773-425-5054
Mailing Address - Fax:
Practice Address - Street 1:76 CARDINAL RIDGE RD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-9834
Practice Address - Country:US
Practice Address - Phone:773-425-5054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004604363A00000X
NC001010965363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant