Provider Demographics
NPI:1841260742
Name:DIEDRICH, PAUL (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:DIEDRICH
Suffix:
Gender:M
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-877-5199
Mailing Address - Fax:
Practice Address - Street 1:2704 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:028-775-1997
Practice Address - Fax:702-363-8753
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA870363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504092Medicaid
NV100504091Medicaid
NV100504092Medicaid
NV100504091Medicaid
Q32574Medicare UPIN