Provider Demographics
NPI:1508862442
Name:BERTRAM, DIANA (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HOSPITAL AVE
Mailing Address - Street 2:STE 113
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1463
Mailing Address - Country:US
Mailing Address - Phone:814-375-3722
Mailing Address - Fax:814-375-3363
Practice Address - Street 1:145 HOSPITAL AVE
Practice Address - Street 2:STE 113
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1463
Practice Address - Country:US
Practice Address - Phone:814-375-3722
Practice Address - Fax:814-375-3363
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP007004B363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP42809Medicare UPIN