Basic Information
| Provider Information | |||||||||
| NPI: | 1982729216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIEDERICH | ||||||||
| FirstName: | DALLAS | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20208 STATE HIGHWAY 155 S | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757625600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038256222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00509 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 202460603 | 05 | TX | MEDICAID | 75-0818167-048 | 01 | TX | TRICARE | OTHER | 75-1976930-005 | 01 | TX | TRICARE | OTHER | 202460602 | 05 | TX | MEDICAID | 75-0818167-044 | 01 | TX | TRICARE | OTHER | 75-0818167-015 | 01 | TX | TRICARE | OTHER | 752616977001 | 01 | TX | TRICARE | OTHER | 8689NN | 01 | TX | BCBS | OTHER | P01478958 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 202460601 | 05 | TX | MEDICAID | 752616977002 | 01 | TX | TRICARE | OTHER | 8EW436 | 01 | TX | BCBS | OTHER | P01478957 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 75-2616977-001 | 01 | TRICARE | OTHER | 8N3412 | 01 | TX | BCBS | OTHER | 202460604 | 05 | TX | MEDICAID | 75-0818167-022 | 01 | TX | TRICARE | OTHER | 752616977028 | 01 | TX | TRICARE | OTHER | 8679NN | 01 | TX | BCBS | OTHER |