Provider Demographics
NPI:1548405533
Name:DIETRICH, MEGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:44405 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5023
Mailing Address - Country:US
Mailing Address - Phone:248-758-7150
Mailing Address - Fax:248-858-3918
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-758-7150
Practice Address - Fax:248-858-3918
Is Sole Proprietor?:No
Enumeration Date:2008-12-05
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005452363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1548405533Medicaid