Provider Demographics
NPI:1235316340
Name:LISS, DIANE LYNN (RPA-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:LISS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 W OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4003
Mailing Address - Country:US
Mailing Address - Phone:516-433-1100
Mailing Address - Fax:516-433-1342
Practice Address - Street 1:87 W OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4003
Practice Address - Country:US
Practice Address - Phone:516-433-1100
Practice Address - Fax:516-433-1342
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005393-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical