Provider Demographics
NPI:1912120957
Name:DITZEL, AMY KMETZ (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:KMETZ
Last Name:DITZEL
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 1:875 OAK ST SE
Mailing Address - Street 2:STE 390
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-399-7520
Mailing Address - Fax:503-362-7344
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:STE 390
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-399-7520
Practice Address - Fax:503-362-7344
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03007363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical