Healthcare Provider Details

I. General information

NPI: 1164268355
Provider Name (Legal Business Name): NOLAN DYKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6675 CORPORATE CENTER PKWY
JACKSONVILLE FL
32216-8079
US

IV. Provider business mailing address

6675 CORPORATE CENTER PKWY
JACKSONVILLE FL
32216-8079
US

V. Phone/Fax

Practice location:
  • Phone: 904-245-8910
  • Fax:
Mailing address:
  • Phone: 904-245-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA1131
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number456457381
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: