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
State | License ID | Taxonomies |
---|---|---|
MI | 5601005452 | 363A00000X, 363AS0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 1548405533 | Medicaid |