Provider Demographics
NPI:1164651956
Name:DINEEN, MIRIAM PATTERSON (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:PATTERSON
Last Name:DINEEN
Suffix:
Gender:F
Credentials:MMS, 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:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:1372 WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2932
Practice Address - Country:US
Practice Address - Phone:336-659-4814
Practice Address - Fax:336-768-4745
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCN443COtherMEDICARE PTAN
NC1164651956Medicaid
VA1164651956Medicaid
NC1871725556Medicaid
NCNCN443A950OtherMEDICARE PTAN