1164651956 NPI number — MIRIAM PATTERSON DINEEN MMS, PA-C

Table of content: MIRIAM PATTERSON DINEEN MMS, PA-C (NPI 1164651956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164651956 NPI number — MIRIAM PATTERSON DINEEN MMS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DINEEN
Provider First Name:
MIRIAM
Provider Middle Name:
PATTERSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MMS, PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164651956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603725
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-3725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-575-2625
Provider Business Mailing Address Fax Number:
828-350-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1372 WESTGATE CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-2932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-659-4814
Provider Business Practice Location Address Fax Number:
336-768-4745
Provider Enumeration Date:
07/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0010-01831 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NCN443C . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1164651956 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164651956 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1871725556 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: NCN443A950 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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