Provider Demographics
NPI:1962890939
Name:DIETRICH, CHRISTOPHER DAVID (PA-C)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:DIETRICH
Suffix:
Gender:
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 1:16600 CENTERFIELD DR STE 205
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7702
Mailing Address - Country:US
Mailing Address - Phone:907-696-7466
Mailing Address - Fax:
Practice Address - Street 1:9860 E TERN DR
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-9103
Practice Address - Country:US
Practice Address - Phone:509-551-1174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2393363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1626073Medicaid