Provider Demographics
NPI:1497875132
Name:TABACHNICK, DIANE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:TABACHNICK
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 1:208 FLYNN AVE STE 3J
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5420
Mailing Address - Country:US
Mailing Address - Phone:802-488-6920
Mailing Address - Fax:802-488-6919
Practice Address - Street 1:300 FLYNN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5301
Practice Address - Country:US
Practice Address - Phone:802-488-6000
Practice Address - Fax:802-488-6919
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04266OtherPA LICENSE