Provider Demographics
NPI:1124060140
Name:DIERS, PAUL (PA-C)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:DIERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 JOHN B DENNIS HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-245-3161
Mailing Address - Fax:423-857-8129
Practice Address - Street 1:2202 JOHN B DENNIS HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-245-3161
Practice Address - Fax:423-857-8129
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA000243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPA000243OtherLICENSE
TN3669582Medicaid
VA008929785Medicaid
TNPA000243OtherLICENSE
TN3669582Medicaid
VA008929785Medicaid