Provider Demographics
NPI:1528026747
Name:CHOREN, DIANA M (PAC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:CHOREN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:M
Other - Last Name:CASTELLUCCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:9875 S FRANKLIN DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8895
Mailing Address - Country:US
Mailing Address - Phone:414-858-2206
Mailing Address - Fax:414-858-2236
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-7299
Practice Address - Fax:770-237-1723
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1310-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI009OtherBCBS
970030813Medicare PIN
WI020701940Medicare PIN
WI009OtherBCBS