Provider Demographics
NPI:1003092370
Name:DIETERLE, KATIE LEE (RPA-C, AAHIVS)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LEE
Last Name:DIETERLE
Suffix:
Gender:F
Credentials:RPA-C, AAHIVS
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LEE
Other - Last Name:BACHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:600 ROE AVE STE 1F
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1676
Practice Address - Country:US
Practice Address - Phone:607-795-8161
Practice Address - Fax:607-795-8115
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02966498Medicaid
NYJ400069560Medicare PIN