Provider Demographics
NPI:1407593569
Name:DIETZ, JOHN K
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:DIETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 BRAGAW ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3435
Mailing Address - Country:US
Mailing Address - Phone:907-433-7363
Mailing Address - Fax:907-274-6413
Practice Address - Street 1:1650 BRAGAW ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3435
Practice Address - Country:US
Practice Address - Phone:907-433-7320
Practice Address - Fax:907-274-6413
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK132289163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty