Provider Demographics
NPI:1629487160
Name:DINIUS, DESIRAE LYNN (PAC)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:LYNN
Last Name:DINIUS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 FAIRWAY ST
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2639
Mailing Address - Country:US
Mailing Address - Phone:701-456-4000
Mailing Address - Fax:701-456-4545
Practice Address - Street 1:2500 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2639
Practice Address - Country:US
Practice Address - Phone:701-456-4000
Practice Address - Fax:701-456-4545
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDHE# 1461268Medicaid
ND71367Medicaid
NDHE# 1461268Medicaid
ND71367Medicaid