Provider Demographics
NPI:1588047583
Name:DEIDIKER, CONSTANCE RICHARDSON (PA-C)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:RICHARDSON
Last Name:DEIDIKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 306556
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6556
Mailing Address - Country:US
Mailing Address - Phone:615-329-2294
Mailing Address - Fax:615-695-1494
Practice Address - Street 1:8 CITY BLVD STE 300
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-2560
Practice Address - Country:US
Practice Address - Phone:615-329-6600
Practice Address - Fax:615-321-6226
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2819363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant