Provider Demographics
NPI:1003965757
Name:STRADER, DIANE (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:STRADER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NEE
Other - Middle Name:
Other - Last Name:WINGATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-636-4300
Mailing Address - Fax:858-636-4319
Practice Address - Street 1:3860 CALLE FORTUNADA
Practice Address - Street 2:STE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4800
Practice Address - Country:US
Practice Address - Phone:858-636-4300
Practice Address - Fax:858-636-4319
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8161363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics