Charles, Jerald Dietrich

Charles, Jerald Dietrich is an individual health care provider with primary practice located at 2845 Greenbrier Rd , Green Bay WI 54311-6519. He recently has 2 registered licenses in different health care specialties including Physician Assistants & Advanced Practice Nursing Providers / Surgical, Physician Assistants & Advanced Practice Nursing Providers / Physician Assistant. Physician Assistants & Advanced Practice Nursing Providers / Physician Assistant is his primary health care specialty. Charles, Jerald Dietrich can be contacted via phone (920) 288-8320.

Contact Information

Primary practice address
2845 Greenbrier Rd Green Bay WI 54311-6519
Phone: (920) 288-8320
Fax:
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Physician Assistants & Advanced Practice Nursing Providers / Surgical 363AS0400X
Physician Assistants & Advanced Practice Nursing Providers / Physician Assistant 363A00000X 4028-023 Wisconsin

Profile Details

NPI number 1396284154
LBN Legal business name Charles, Jerald Dietrich
Credentials Physician's Assistant Certified (PA-C)
Entity Individual
Sole proprietor 1 No
Enumeration date Feb 13th, 2017
Last updated Dec 14th, 2021 - about 5 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1396284154 NPPES
Wisconsin MEDICAID 100068010

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