Provider Demographics
NPI:1164708111
Name:DIETZ, DOROTA MARIA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DOROTA
Middle Name:MARIA
Last Name:DIETZ
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 1:5155 E EAGLE DR UNIT 20730
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-3031
Mailing Address - Country:US
Mailing Address - Phone:480-706-9430
Mailing Address - Fax:480-378-2273
Practice Address - Street 1:5155 E EAGLE DR UNIT 20730
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85277-3031
Practice Address - Country:US
Practice Address - Phone:480-706-9430
Practice Address - Fax:480-378-2273
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4994363A00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ155246Medicare PIN