Provider Demographics
NPI:1689918278
Name:DIETRICH, LUCAS ALAN (PA)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:ALAN
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4007
Mailing Address - Country:US
Mailing Address - Phone:336-765-0383
Mailing Address - Fax:336-768-1737
Practice Address - Street 1:3001 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4007
Practice Address - Country:US
Practice Address - Phone:336-765-0383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3555363A00000X
NC0010-08128363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant