Provider Demographics
NPI:1477942639
Name:MOLLER, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MOLLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:MOLLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:34 N HENRY ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1929
Mailing Address - Country:US
Mailing Address - Phone:516-551-1071
Mailing Address - Fax:
Practice Address - Street 1:10201 66TH RD
Practice Address - Street 2:NORTH SHORE- LIJ FOREST HILLS,
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2029
Practice Address - Country:US
Practice Address - Phone:718-830-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018309-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11-3465690Medicaid