Provider Demographics
NPI:1225135536
Name:BOLEN, DIANNA GAIL (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DIANNA
Middle Name:GAIL
Last Name:BOLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:GAIL
Other - Last Name:ADKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:176 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-1064
Mailing Address - Country:US
Mailing Address - Phone:304-438-6188
Mailing Address - Fax:304-438-6819
Practice Address - Street 1:8971 SEWELL CREEK ROAD
Practice Address - Street 2:
Practice Address - City:MEADOW BRIDGE
Practice Address - State:WV
Practice Address - Zip Code:25976
Practice Address - Country:US
Practice Address - Phone:304-438-6188
Practice Address - Fax:304-438-6819
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1072834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant