Individual
MARK B DIETRICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
384 ROARK LN, MC DONALD, TN 37353-5238
(423) 503-6343
Mailing address
384 ROARK LN, MC DONALD, TN 37353-5238
(423) 503-6343
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
APN12260
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002470891B
—
GA
05
—
104592
—
AL
05
—
1509502
—
TN
01
—
4185343
BLUE CROSS BLUE SHIELD TN
TN
05
—
8053520
—
NC
01
—
N457415
WELLCARE (GA MEDICAID)
GA
01
—
P00744539
RAILROAD MEDICARE
TN
Enumeration date
11/07/2006
Last updated
01/24/2023
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