Provider Demographics
NPI:1790730299
Name:DIETZ, GORDON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:
Last Name:DIETZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 E MAIN ST
Mailing Address - Street 2:BERTRAND CHAFFEE HOSPITAL
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1443
Mailing Address - Country:US
Mailing Address - Phone:716-592-2871
Mailing Address - Fax:716-794-0025
Practice Address - Street 1:224 E MAIN ST
Practice Address - Street 2:BERTRAND CHAFFEE HOSPITAL
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1443
Practice Address - Country:US
Practice Address - Phone:716-592-2871
Practice Address - Fax:716-794-0025
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR103713367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007496140 0004Medicaid
PA050514OtherGROUP MEDICARE #
PARN326868LOtherRN LICENSE PA
PA022707P1KMedicare PIN