Basic Information
| Provider Information | |||||||||
| NPI: | 1134198054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 W 5TH AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093442663 | ||||||||
| FaxNumber: | 5096249179 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W 5TH AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093442663 | ||||||||
| FaxNumber: | 5096249179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10002321 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0156193 | 01 | WA | DEPT OF LABOR & INDUSTRIE | OTHER | 8934606 | 01 | WA | CRIME VICTIMS | OTHER | 4305DI | 01 | WA | ASURIS NW HEALTH | OTHER | 5847 | 01 | WA | GROUP HEALTH NW | OTHER | 000010149524 | 01 | ID | REGENCE BLUE SHIELD OF ID | OTHER | 8387292 | 05 | WA | MEDICAID | K6401 | 01 | ID | BLUE CROSS OF ID | OTHER |