Provider Demographics
NPI:1932164324
Name:DIEM, RONNIE N (PAC)
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:N
Last Name:DIEM
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 1:4601 S DUPONT HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-6405
Mailing Address - Country:US
Mailing Address - Phone:302-331-9026
Mailing Address - Fax:
Practice Address - Street 1:4601 S DUPONT HWY
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6405
Practice Address - Country:US
Practice Address - Phone:302-331-9026
Practice Address - Fax:302-698-1187
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000036127Medicaid
Q26330Medicare UPIN
DE015040S72Medicare ID - Type Unspecified