Provider Demographics
NPI:1427127190
Name:DIETRICH, MARK B (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 ROARK LN
Mailing Address - Street 2:
Mailing Address - City:MC DONALD
Mailing Address - State:TN
Mailing Address - Zip Code:37353-5238
Mailing Address - Country:US
Mailing Address - Phone:423-503-6343
Mailing Address - Fax:
Practice Address - Street 1:384 ROARK LN
Practice Address - Street 2:
Practice Address - City:MC DONALD
Practice Address - State:TN
Practice Address - Zip Code:37353-5238
Practice Address - Country:US
Practice Address - Phone:423-503-6343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN12260367500000X
TNRN128321367500000X
GARN169347367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL104592Medicaid
TNP00744539OtherRAILROAD MEDICARE
TN1509502Medicaid
GAN457415OtherWELLCARE (GA MEDICAID)
GA002470891BMedicaid
TN4185343OtherBLUE CROSS BLUE SHIELD TN
NC8053520Medicaid
TN1509502Medicaid