Healthcare Provider Details

I. General information

NPI: 1538805049
Provider Name (Legal Business Name): RACHEL MARIE DIESSNER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2022
Last Update Date: 08/04/2024
Certification Date: 08/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N BECKLEY AVE
DALLAS TX
75203-1201
US

IV. Provider business mailing address

6451 BRENTWOOD STAIR RD STE 200
FORT WORTH TX
76112-3200
US

V. Phone/Fax

Practice location:
  • Phone: 214-947-8181
  • Fax:
Mailing address:
  • Phone: 817-496-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15699
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15699
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: