Provider Demographics
NPI:1891404232
Name:DIETRICH, DEANNA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:NICOLE
Last Name:DIETRICH
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 1:501 HANNIBAL ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1015
Mailing Address - Country:US
Mailing Address - Phone:315-887-1059
Mailing Address - Fax:
Practice Address - Street 1:501 HANNIBAL ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1015
Practice Address - Country:US
Practice Address - Phone:315-887-1059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116592363A00000X, 207P00000X
NY031818-01363A00000X
COPA.0007617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116239300Medicaid