MEDICARE: MANDI DIEDERICH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1487463089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANDI DIEDERICH PA-C

Provider Business Mailing Address
First Line	:	404 S HANOVER ST
Second Line	:
City	:	HANOVER
State	:	KS
Zip	:	66945-8862
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 WESTPORT PL
Second Line	:
City	:	MANHATTAN
State	:	KS
Zip	:	66502-2913
Country	:	US
Telephone Number	:	785-539-9218
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2025
Last Update Date	:	01/07/2025

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Directions to “ MANDI DIEDERICH PA-C” Practice Location

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