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General NPI Number Information
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NPI Number | 1386067304
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Entity Type | Individual
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Provider Name | VIRGUST JUSTICE DYKES P.A.
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Gender | Male
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Dates
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Enumeration Date | 01/27/2014
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Last Update Date | 07/24/2017
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Provider Practice Location Address
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Address Line | 668 W BRAZOS AVE
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City | WEST COLUMBIA
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State | TX
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Zip | 77486-2616
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Country | US
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Telephone | 979-345-2525
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Fax |
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Provider Business Mailing Address
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Address Line | 2600 FM 1764 RD STE 190
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City | LA MARQUE
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State | TX
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Zip | 77568-2826
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Country | US
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Telephone | 281-886-8964
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA08778
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA08778
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License Number State | TX
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