Healthcare Provider Details

I. General information

NPI: 1780187633
Provider Name (Legal Business Name): TIFFANY DIETZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S SHIRLINGTON RD STE 102
ARLINGTON VA
22206-3603
US

IV. Provider business mailing address

11350 MCCORMICK RD BUILDING 1, SUITE 501
HUNT VALLEY MD
21031
US

V. Phone/Fax

Practice location:
  • Phone: 703-738-4336
  • Fax:
Mailing address:
  • Phone: 410-329-1071
  • Fax: 410-329-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006117
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: