Provider Demographics
NPI:1275802332
Name:PEREZ - SOLANO, DIANA E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:E
Last Name:PEREZ - SOLANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:E
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:574-335-6850
Mailing Address - Fax:574-335-0849
Practice Address - Street 1:611 E DOUGLAS RD STE 207
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1465
Practice Address - Country:US
Practice Address - Phone:574-335-6850
Practice Address - Fax:574-335-0849
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002769A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102555349OtherANTHEM
IN300035174Medicaid