Basic Information
| Provider Information | |||||||||
| NPI: | 1790730299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETZ | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 E MAIN ST | ||||||||
| Address2: | BERTRAND CHAFFEE HOSPITAL | ||||||||
| City: | SPRINGVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141411443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165922871 | ||||||||
| FaxNumber: | 7167940025 | ||||||||
| Practice Location | |||||||||
| Address1: | 224 E MAIN ST | ||||||||
| Address2: | BERTRAND CHAFFEE HOSPITAL | ||||||||
| City: | SPRINGVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141411443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165922871 | ||||||||
| FaxNumber: | 7167940025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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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 | 367500000X | R103713 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 007496140 0004 | 05 | PA | MEDICAID | 050514 | 01 | PA | GROUP MEDICARE # | OTHER | RN326868L | 01 | PA | RN LICENSE PA | OTHER |