Provider Demographics
NPI:1649221599
Name:DEMERS, DIANNE K (PA)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:K
Last Name:DEMERS
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 1:390 MAIN ST STE 509
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-2581
Mailing Address - Country:US
Mailing Address - Phone:508-756-6324
Mailing Address - Fax:
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-756-6324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
42523OtherCHILDRENS MEDICAL SECURIT
042472266OtherTHREE RIVERS
042472266OtherTRICARE CHAMPUS
381306OtherMVP HEALTH CARE
67868OtherFALLON COMMUNITY HEALTH P
8301692OtherEVERCARE
AP2101OtherMEDICARE B
42523OtherHEALTHY START
381306OtherMVP HEALTH CARE