Provider Demographics
NPI:1386672897
Name:SCHUMITZ, DIANA B (PA)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:B
Last Name:SCHUMITZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:BOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:173 BORRMANN RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-1309
Mailing Address - Country:US
Mailing Address - Phone:203-467-1890
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000640363A00000X
CT640363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ05853Medicare UPIN
CT970001242Medicare ID - Type Unspecified