Provider Demographics
NPI:1093073710
Name:PASTOR, DIANE KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KATHLEEN
Last Name:PASTOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 LORD JOES LNDG
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1570
Mailing Address - Country:US
Mailing Address - Phone:631-754-6819
Mailing Address - Fax:
Practice Address - Street 1:4 LORD JOES LNDG
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-1570
Practice Address - Country:US
Practice Address - Phone:631-754-6819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305997-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health