Provider Demographics
NPI:1558517912
Name:DANG, DIEM JILLIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:DIEM
Middle Name:JILLIAN
Last Name:DANG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIEM
Other - Middle Name:JILLIAN
Other - Last Name:TRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4451
Mailing Address - Fax:970-490-4199
Practice Address - Street 1:25 MONUMENT RD
Practice Address - Street 2:SUITE 190
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5060
Practice Address - Country:US
Practice Address - Phone:717-851-6454
Practice Address - Fax:717-851-1665
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002789363A00000X
WV01575363A00000X
PAMA056113363A00000X
COPA.0004666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2981455OtherHIGHMARK BLUE SHIELD-FREEDOM BLUE
PA294025FLTMedicare PIN
OHPA36731Medicare PIN