Provider Demographics
NPI:1457029043
Name:VAN DIJK, NICOLAAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICOLAAS
Middle Name:
Last Name:VAN DIJK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WABASHA ST N STE 260
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1147
Mailing Address - Country:US
Mailing Address - Phone:952-831-8742
Mailing Address - Fax:
Practice Address - Street 1:400 WABASHA ST N STE 260
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1147
Practice Address - Country:US
Practice Address - Phone:952-831-8742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12435225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12435OtherMINNESOTA BOARD OF PHYSICAL THERAPY