Provider Demographics
NPI:1407447220
Name:SAVARESE, DIANE P (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:P
Last Name:SAVARESE
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 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-793-9715
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:1550 S PIONEER WAY STE 100
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4637
Practice Address - Country:US
Practice Address - Phone:509-793-9790
Practice Address - Fax:509-764-3255
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008128207PE0004X
IL085008128363A00000X
WAPA61366311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2223019Medicaid