Healthcare Provider Details

I. General information

NPI: 1265425623
Provider Name (Legal Business Name): JANA B. DIETERICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 S CEDAR CREST BLVD SUITE 1200
ALLENTOWN PA
18103-6256
US

IV. Provider business mailing address

PO BOX 783311
PHILADELPHIA PA
19178-3311
US

V. Phone/Fax

Practice location:
  • Phone: 610-437-6222
  • Fax: 610-437-5910
Mailing address:
  • Phone: 484-884-0183
  • Fax: 484-884-0628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA051165
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: