Healthcare Provider Details

I. General information

NPI: 1760234892
Provider Name (Legal Business Name): JOSHUA DIETERMAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 E CHAPMAN AVE
FULLERTON CA
92832-2011
US

IV. Provider business mailing address

631 ASH WAY
LA HABRA CA
90631-5978
US

V. Phone/Fax

Practice location:
  • Phone: 714-992-7093
  • Fax: 714-992-9923
Mailing address:
  • Phone: 562-475-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number95135839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: