Provider Demographics
NPI:1053891168
Name:DIRKSEN, KEVIN M (APRN-CNP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:DIRKSEN
Suffix:
Gender:M
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-300-1129
Mailing Address - Fax:419-394-9575
Practice Address - Street 1:801 PRO DR STE D2
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-3307
Practice Address - Country:US
Practice Address - Phone:419-586-6480
Practice Address - Fax:419-586-8574
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023488363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105065OtherGROUP MEDICAID - JTDM FAMILY PRACTICE, LLC
OH0313733Medicaid
OH9934723OtherGROUP PTAN - JTDM FAMILY PRACTICE, LLC
OHH674260OtherMEDICARE