Provider Demographics
NPI:1548596166
Name:DYKES, MATTHEW GREGORY (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GREGORY
Last Name:DYKES
Suffix:
Gender:M
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 1:3890 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5803
Mailing Address - Country:US
Mailing Address - Phone:228-872-6291
Mailing Address - Fax:228-872-7627
Practice Address - Street 1:3890 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5803
Practice Address - Country:US
Practice Address - Phone:228-872-6291
Practice Address - Fax:228-872-7627
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA000124363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3021973674Medicare PIN