Provider Demographics
NPI:1376645275
Name:ORTMAN, DIANA J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:J
Last Name:ORTMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:GARRISONVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22463-0729
Mailing Address - Country:US
Mailing Address - Phone:540-720-0400
Mailing Address - Fax:540-657-4366
Practice Address - Street 1:422 GARRISONVILLE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-1573
Practice Address - Country:US
Practice Address - Phone:540-720-8000
Practice Address - Fax:540-657-4366
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110002374OtherVIRGINIA LICENSE