Provider Demographics
NPI: | 1649568668 |
---|---|
Name: | TSCHUDI, DIANE BETH (PA) |
Entity Type: | Individual |
Prefix: | |
First Name: | DIANE |
Middle Name: | BETH |
Last Name: | TSCHUDI |
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: | 5100 W TAFT RD |
Mailing Address - Street 2: | SUITE 1C |
Mailing Address - City: | LIVERPOOL |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 13088-3807 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 315-452-2333 |
Mailing Address - Fax: | 315-452-2336 |
Practice Address - Street 1: | 5100 W TAFT RD |
Practice Address - Street 2: | SUITE 1C |
Practice Address - City: | LIVERPOOL |
Practice Address - State: | NY |
Practice Address - Zip Code: | 13088-3807 |
Practice Address - Country: | US |
Practice Address - Phone: | 315-452-2333 |
Practice Address - Fax: | 315-452-2336 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-07-11 |
Last Update Date: | 2013-03-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
NY | 015184 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 03536523 | Medicaid | |
NY | 03536523 | Medicaid |