Healthcare Provider Details

I. General information

NPI: 1386067304
Provider Name (Legal Business Name): VIRGUST JUSTICE DYKES P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 W BRAZOS AVE
WEST COLUMBIA TX
77486-2616
US

IV. Provider business mailing address

2600 FM 1764 RD STE 190
LA MARQUE TX
77568-2826
US

V. Phone/Fax

Practice location:
  • Phone: 979-345-2525
  • Fax:
Mailing address:
  • Phone: 281-886-8964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA08778
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA08778
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: