Provider Demographics
NPI:1154578193
Name:DIETRICH, PAUL G (PTA)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:G
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:SUITE 100 CONSONUS HEALTHCARE SERVICES
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5167
Mailing Address - Fax:971-206-5209
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:SUITE 100 CONSONUS HEALTHCARE SERVICES
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:971-206-5167
Practice Address - Fax:971-206-5209
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83-019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist