Provider Demographics
NPI:1407811995
Name:FITCH, DIANE K (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:FITCH
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 1:1021 NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1436
Mailing Address - Country:US
Mailing Address - Phone:712-252-2477
Mailing Address - Fax:712-252-5920
Practice Address - Street 1:1021 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1436
Practice Address - Country:US
Practice Address - Phone:712-252-2477
Practice Address - Fax:712-252-5920
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000656363AM0700X
NE511363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1201002OtherMEDICARE PTAN
53002OtherWELLMARK BCBS OF IOWA
SD6828970Medicaid
P00353384OtherMEDICARE RAILROAD
NER78165Medicare UPIN
53002OtherWELLMARK BCBS OF IOWA