Provider Demographics
NPI:1972708402
Name:DIERKES, SUSAN PATRICIA (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:PATRICIA
Last Name:DIERKES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 MORROW ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:DRESDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38225-1846
Mailing Address - Country:US
Mailing Address - Phone:731-364-3353
Mailing Address - Fax:731-364-3373
Practice Address - Street 1:811 MORROW ST
Practice Address - Street 2:SUITE 208
Practice Address - City:DRESDEN
Practice Address - State:TN
Practice Address - Zip Code:38225-1846
Practice Address - Country:US
Practice Address - Phone:731-364-3353
Practice Address - Fax:731-364-3373
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1493363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36651031Medicaid
TN4180537OtherBCBS
TN43637OtherTLC
TN36651031Medicare PIN