Basic Information
| Provider Information | |||||||||
| NPI: | 1386309342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETTER | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | EMBERLEE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2587 RAVENHILL DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283035451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103231545 | ||||||||
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| Practice Location | |||||||||
| Address1: | 609 ATTAIN ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | FUQUAY VARINA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275261984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195670684 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2021 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-11703 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.