Provider Demographics
NPI:1437799590
Name:DITTRICH, AUSTIN JACOB (PA)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JACOB
Last Name:DITTRICH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 GATEWAY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:817-419-4605
Practice Address - Street 1:811 W INTERSTATE 20 STE 114
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-5871
Practice Address - Country:US
Practice Address - Phone:817-784-8268
Practice Address - Fax:817-804-8178
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant