Healthcare Provider Details

I. General information

NPI: 1851365035
Provider Name (Legal Business Name): PATRICIA ANNE DYKSTRA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

597 MERRIMACK ST LOWELL COMMUNITY HEALTH CENTER
LOWELL MA
01854
US

IV. Provider business mailing address

597 MERRIMACK ST LOWELL COMMUNITY HEALTH CENTER
LOWELL MA
01854
US

V. Phone/Fax

Practice location:
  • Phone: 978-937-9700
  • Fax: 978-446-9830
Mailing address:
  • Phone: 978-937-9700
  • Fax: 978-446-9830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number77409
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number77409
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: