Provider Demographics
NPI:1740560382
Name:DEDIC, NATHAN ADAM (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ADAM
Last Name:DEDIC
Suffix:
Gender:M
Credentials:MS, PA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:280 S MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3852
Practice Address - Country:US
Practice Address - Phone:714-634-4569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21763363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant