Provider Demographics
NPI:1053387522
Name:DIETRICH, AMY L (PA C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:705 SIOUX POINT RD
Mailing Address - Street 2:STE 100
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049
Mailing Address - Country:US
Mailing Address - Phone:605-217-5500
Mailing Address - Fax:605-217-5515
Practice Address - Street 1:705 SIOUX POINT RD
Practice Address - Street 2:STE 100
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049
Practice Address - Country:US
Practice Address - Phone:605-217-5500
Practice Address - Fax:605-217-5515
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0598363A00000X
SDL1728363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S74494Medicare UPIN