Provider Demographics
NPI:1841691003
Name:DYKSTRA, AARON (NP)
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 COTTONWOOD CT STE 150
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6550
Mailing Address - Country:US
Mailing Address - Phone:208-260-5431
Mailing Address - Fax:
Practice Address - Street 1:100 COTTONWOOD CT STE 150
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6550
Practice Address - Country:US
Practice Address - Phone:208-260-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201703051363LF0000X
ID55392363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily