Provider Demographics
NPI:1508352790
Name:FIRESTONE, DILLAN NICOLE
Entity Type:Individual
Prefix:
First Name:DILLAN
Middle Name:NICOLE
Last Name:FIRESTONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 FULTON LN
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1016
Mailing Address - Country:US
Mailing Address - Phone:480-254-9145
Mailing Address - Fax:
Practice Address - Street 1:6 WOODLAND RD STE 202
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574
Practice Address - Country:US
Practice Address - Phone:707-968-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
CAPA56930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical