=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811056633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH JEAN DIETRICH PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2006
-----------------------------------------------------
Last Update Date | 11/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 9TH ST
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97439-9470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-902-1634
-----------------------------------------------------
Fax | 541-902-9702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 24410
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97402-0451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-984-4301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA01118
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------