Provider Demographics
NPI:1922561091
Name:DIETER, MELISSA (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DIETER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:WOERTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4020 US HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-1333
Mailing Address - Country:US
Mailing Address - Phone:863-314-0020
Mailing Address - Fax:863-314-0024
Practice Address - Street 1:4020 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1333
Practice Address - Country:US
Practice Address - Phone:863-314-0020
Practice Address - Fax:863-314-0024
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant