Provider Demographics
NPI:1316957582
Name:DIETZ, MARYETTA (CRNP)
Entity type:Individual
Prefix:
First Name:MARYETTA
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 N IH 35
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1926
Mailing Address - Country:US
Mailing Address - Phone:512-324-8300
Mailing Address - Fax:512-324-8301
Practice Address - Street 1:1600 W 38TH ST
Practice Address - Street 2:SUITE 308
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6400
Practice Address - Country:US
Practice Address - Phone:512-324-3540
Practice Address - Fax:512-324-3541
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX760224363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204269903Medicaid
TX819N67OtherBCBS
TX204269904Medicaid
TX819N67OtherBCBS
TXTXB106349Medicare PIN