Provider Demographics
NPI:1194897264
Name:DILDINE, ERIC S (PA-C)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:DILDINE
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:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-7715
Mailing Address - Fax:541-706-7742
Practice Address - Street 1:2275 NE DOCTORS DR.
Practice Address - Street 2:SUITE 5
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-706-7715
Practice Address - Fax:541-706-7742
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01169363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00479095OtherRAILROAD MEDICARE
OR11745011OtherCAQH ID
OR500608143Medicaid
OR500608143Medicaid