Provider Demographics
NPI:1457307548
Name:NOLLER, DIANA T (PA, C)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:T
Last Name:NOLLER
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 1:737 MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-3089
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:609-518-1868
Practice Address - Street 1:737 MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-3089
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:609-518-1868
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMP144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ51864Medicare UPIN
NJ137317Medicare ID - Type Unspecified