Provider Demographics
NPI:1124008354
Name:DEJONG, DIANE L (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:DEJONG
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SULLY
Mailing Address - State:IA
Mailing Address - Zip Code:50251-1016
Mailing Address - Country:US
Mailing Address - Phone:641-594-3150
Mailing Address - Fax:641-594-3795
Practice Address - Street 1:704 3RD ST
Practice Address - Street 2:
Practice Address - City:SULLY
Practice Address - State:IA
Practice Address - Zip Code:50251-1016
Practice Address - Country:US
Practice Address - Phone:641-594-3150
Practice Address - Fax:641-594-3795
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001494363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP96804Medicare UPIN
IA163449Medicare ID - Type UnspecifiedMONROE FAMILY HEALTH
IAI10420Medicare PIN
IA163455Medicare ID - Type UnspecifiedSULLY FAMILY HEALTH
IAI10420Medicare ID - Type UnspecifiedPELLA MEDICAL CLINIC