Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | A157293 | CA |
NPI | 1003304536 |
---|---|
Provider Name | Marlowe Gates Dieckmann |
First Address | Grass Valley, CA 95945-5208 |
Second Address | Grass Valley, CA 95945-5208 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/04/2018 |
Last Update Date | 02/09/2020 |