Provider Demographics
NPI:1528387826
Name:ANDRUSYSHYN, DIANA (APRN)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:ANDRUSYSHYN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3644
Mailing Address - Country:US
Mailing Address - Phone:508-778-4777
Mailing Address - Fax:508-771-9555
Practice Address - Street 1:433 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3644
Practice Address - Country:US
Practice Address - Phone:508-778-4777
Practice Address - Fax:508-771-9555
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004236363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236Medicaid
CT004236Medicaid
CT004236Medicare Oscar/Certification
CT004236Medicare UPIN