Provider Demographics
NPI:1497115497
Name:WOODS, DI'ARA (PA-C)
Entity Type:Individual
Prefix:
First Name:DI'ARA
Middle Name:
Last Name:WOODS
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 1:403 GLEN CARBON RD
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2965
Mailing Address - Country:US
Mailing Address - Phone:314-749-8906
Mailing Address - Fax:
Practice Address - Street 1:3 CLUB CENTRE CT STE B1
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3519
Practice Address - Country:US
Practice Address - Phone:618-699-4402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGOtherRR MEDICARE
MOPENDINGMedicaid
MOPENDINGMedicare PIN