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General NPI Number Information
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NPI Number | 1538943618
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Entity Type | Individual
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Provider Name | GRANT MICHAEL DIETZ PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/21/2023
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Last Update Date | 11/23/2025
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Provider Practice Location Address
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Address Line | 10115 E 80TH ST STE A
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City | TULSA
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State | OK
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Zip | 74133-3421
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Country | US
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Telephone | 918-994-4400
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Fax |
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Provider Business Mailing Address
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Address Line | 3111 AZALEA PARK DR
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City | MUSKOGEE
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State | OK
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Zip | 74401-2284
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Country | US
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Telephone | 918-608-1382
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5700
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License Number State | OK
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