Provider Demographics
NPI:1609155977
Name:WINE, DIANNA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:ELIZABETH
Last Name:WINE
Suffix:
Gender:F
Credentials: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:PO BOX 631863
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14163 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-6523
Practice Address - Country:US
Practice Address - Phone:804-893-8702
Practice Address - Fax:804-767-5755
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055676363A00000X
VA0110008014363A00000X
NJ25MP00257500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA350845Medicare PIN