Provider Demographics
NPI:1093867251
Name:WACHTEL, DIANNA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:LYNN
Last Name:WACHTEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:LYNN
Other - Last Name:LANPHEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-0112
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:1112 S CUSHMAN AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3631
Practice Address - Country:US
Practice Address - Phone:253-593-2144
Practice Address - Fax:253-593-4125
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8362063Medicaid
WA8362063Medicaid
P35288Medicare UPIN