Provider Demographics
NPI:1063639524
Name:MYERS, DIANE (PA)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:MYERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S IDAHO ST
Mailing Address - Street 2:STE 100
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-6047
Mailing Address - Country:US
Mailing Address - Phone:562-690-0400
Mailing Address - Fax:
Practice Address - Street 1:2707 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2249
Practice Address - Country:US
Practice Address - Phone:316-691-0249
Practice Address - Fax:316-691-9875
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS961103T00000X
MOPY01796103TC0700X
MOSW0017711041C0700X
CAPA54144363A00000X
KS15-01466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100212200BMedicaid
KS100212200BMedicaid
KS171800Medicare PIN