Provider Demographics
NPI:1447243522
Name:MEDINA, DIANA VIOLA (ANP C)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:VIOLA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:ANP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 SOUTHWESTERN BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-667-1980
Mailing Address - Fax:716-667-1982
Practice Address - Street 1:3775 SOUTHWESTERN BLVD
Practice Address - Street 2:STE A
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127
Practice Address - Country:US
Practice Address - Phone:716-667-1980
Practice Address - Fax:716-667-1982
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303935-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY147122CGOtherPREFERRED CARE
NY000560866001OtherBCBS
NY00026761101OtherUNIVERA
NY9512629OtherINDEPENDENT HEALTH
NY147122CGOtherPREFERRED CARE
NYRA2679Medicare ID - Type Unspecified