Healthcare Provider Details

I. General information

NPI: 1932661352
Provider Name (Legal Business Name): KYLE PHILLIP DIETRICH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2177 W IRONWOOD CENTER DR
COEUR D ALENE ID
83814-2639
US

IV. Provider business mailing address

2177 W IRONWOOD CENTER DR
COEUR D ALENE ID
83814-2639
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6111
  • Fax: 208-625-6112
Mailing address:
  • Phone: 208-625-6111
  • Fax: 208-625-6112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7381730
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-LMT-LIC-15881
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: