Provider Demographics
NPI:1932127149
Name:DYKEMA, PATRICIA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:DYKEMA
Suffix:
Gender:F
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:PO BOX 11407 DEPT #1622
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-1622
Mailing Address - Country:US
Mailing Address - Phone:912-819-8427
Mailing Address - Fax:
Practice Address - Street 1:5353 REYNOLDS ST STE 107
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6089
Practice Address - Country:US
Practice Address - Phone:912-819-7630
Practice Address - Fax:912-819-5860
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4589363A00000X
SCTL3290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA257354264AMedicaid
GAQ52831Medicare UPIN
GA257354264AMedicaid