Provider Demographics
NPI:1922156421
Name:DIEDE, DALE DARWIN (PAC)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:DARWIN
Last Name:DIEDE
Suffix:
Gender:M
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:PO BOX 46
Mailing Address - Street 2:
Mailing Address - City:EKALAKA
Mailing Address - State:MT
Mailing Address - Zip Code:59324-0046
Mailing Address - Country:US
Mailing Address - Phone:406-775-8738
Mailing Address - Fax:406-775-6479
Practice Address - Street 1:202 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1943
Practice Address - Country:US
Practice Address - Phone:406-345-3306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT93083OtherBLUE CROSS
MT0437606Medicaid
P28649Medicare UPIN