Provider Demographics
NPI:1487687422
Name:ERIANNE, DIANE (PA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ERIANNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 FRANKLIN ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1221
Mailing Address - Country:US
Mailing Address - Phone:203-709-8873
Mailing Address - Fax:203-709-8689
Practice Address - Street 1:75 E NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4532
Practice Address - Country:US
Practice Address - Phone:973-436-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00283000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970001274Medicare PIN
CTS93649Medicare UPIN