Provider Demographics
NPI:1093843070
Name:BRYAN, DIANE J (PNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:J
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:J
Other - Last Name:POSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2702 N. 3RD ST.
Mailing Address - Street 2:STE. 4020
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1130
Mailing Address - Country:US
Mailing Address - Phone:602-323-3396
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:635 E. BASELINE RD.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-1235
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN033350363LP0200X
AZAP0100363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173295Medicaid