Healthcare Provider Details

I. General information

NPI: 1104207448
Provider Name (Legal Business Name): CHRISTOPHER JOHN DYKYJ PA-C, ATC, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3188 BELLEVUE AVE
CINCINNATI OH
45219-2369
US

IV. Provider business mailing address

PO BOX 636256
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-5661
  • Fax: 513-475-7348
Mailing address:
  • Phone: 135-856-2005
  • Fax: 513-245-3672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006991RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.004389
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: