Provider Demographics
NPI:1205867751
Name:WEBER, DIANE MURIEL (PA C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MURIEL
Last Name:WEBER
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:MURIEL
Other - Last Name:KRANZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:PO BOX 6020
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6020
Mailing Address - Country:US
Mailing Address - Phone:605-342-3280
Mailing Address - Fax:605-721-8445
Practice Address - Street 1:2820 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5462
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:605-721-8445
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0304363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R25106Medicare UPIN
SD6826405Medicaid
SD4994699OtherWELLMARK
SD5300880Medicaid
SD433889Medicare ID - Type Unspecified