Provider Demographics
NPI:1003802752
Name:YASTRUB, DIANE J (FNP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:J
Last Name:YASTRUB
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9937 E HIDDEN TREASURE CT
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-5876
Mailing Address - Country:US
Mailing Address - Phone:516-313-5563
Mailing Address - Fax:
Practice Address - Street 1:9937 E HIDDEN TREASURE CT
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-5876
Practice Address - Country:US
Practice Address - Phone:516-313-5563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332974-1363LF0000X
AZ235723363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02077645Medicaid
NYP2374172OtherOXFORD PROVIDER NUMBER
NY05240Medicare PIN
NY500026786Medicare PIN
NYP14733Medicare UPIN
NY96N521Medicare PIN