Provider Demographics
NPI:1588663082
Name:ALFORD, DIANA DUBOIS (PA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:DUBOIS
Last Name:ALFORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602108
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2108
Mailing Address - Country:US
Mailing Address - Phone:843-792-2300
Mailing Address - Fax:
Practice Address - Street 1:602 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6627
Practice Address - Country:US
Practice Address - Phone:843-876-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC996363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00851397OtherRR MEDICARE PTAN
SC0315PAMedicaid
SCGP4999OtherMEDICAID GROUP
SCQ38786Medicare UPIN
SC0315PAMedicaid
SCAA07967498Medicare PIN