Provider Demographics
NPI:1598792673
Name:AVERA, DIANE G (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:G
Last Name:AVERA
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 SMYTH RD
Mailing Address - Street 2:VA MEDICAL CENTER
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-7004
Mailing Address - Country:US
Mailing Address - Phone:603-624-4366
Mailing Address - Fax:
Practice Address - Street 1:718 SMYTH RD
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-7004
Practice Address - Country:US
Practice Address - Phone:603-624-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant