Basic Information
Provider Information | |||||||||
NPI: | 1871987818 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIESEL | ||||||||
FirstName: | ALISON | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LATHROUM | ||||||||
OtherFirstName: | ALISON | ||||||||
OtherMiddleName: | M. | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10324 OLD OCEAN CITY BLVD. | ||||||||
Address2: |   | ||||||||
City: | BERLIN | ||||||||
State: | MD | ||||||||
PostalCode: | 21811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106290041 | ||||||||
FaxNumber: | 4106290544 | ||||||||
Practice Location | |||||||||
Address1: | 10324 OLD OCEAN CITY BLVD. | ||||||||
Address2: |   | ||||||||
City: | BERLIN | ||||||||
State: | MD | ||||||||
PostalCode: | 21811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106290041 | ||||||||
FaxNumber: | 4106290544 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2015 | ||||||||
LastUpdateDate: | 06/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | C05717 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | C05717 | 01 | MD | MD MEDICAL LICENSE | OTHER |