Provider Demographics
NPI:1518037878
Name:DIEMER, DOUGLAS R (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:DIEMER
Suffix:
Gender:M
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 1:3200 W CENTRE AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4889
Mailing Address - Country:US
Mailing Address - Phone:269-324-0799
Mailing Address - Fax:269-324-8013
Practice Address - Street 1:3200 W CENTRE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4889
Practice Address - Country:US
Practice Address - Phone:269-324-0799
Practice Address - Fax:269-324-8013
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1151100074OtherBCBS
MI4179846Medicaid
MI2953900670OtherBLUE CROSS BLUE SHIELD
MI4173074Medicaid
MI2953900670OtherBLUE CROSS BLUE SHIELD
MIP14590001Medicare ID - Type Unspecified
MI4173074Medicaid