Provider Demographics
NPI:1346381639
Name:DIETZ, HEATHER JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:JEAN
Last Name:DIETZ
Suffix:
Gender:F
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 1:420 W MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-429-1627
Mailing Address - Fax:208-344-2104
Practice Address - Street 1:420 W MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-429-1627
Practice Address - Fax:208-344-2104
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAYF0OtherBLUE CROSS NON-PAR PIN
ID000010151786OtherBLUE SHIELD NON-PAR PIN
IDPAYF0OtherBLUE CROSS NON-PAR PIN