Healthcare Provider Details

I. General information

NPI: 1407811995
Provider Name (Legal Business Name): DIANE K. FITCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 NEBRASKA ST
SIOUX CITY IA
51105-1436
US

IV. Provider business mailing address

1021 NEBRASKA ST
SIOUX CITY IA
51105-1436
US

V. Phone/Fax

Practice location:
  • Phone: 712-252-2477
  • Fax: 712-252-5920
Mailing address:
  • Phone: 712-252-2477
  • Fax: 712-252-5920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000656
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number511
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: