Provider Demographics
NPI:1689667727
Name:AVERY, DIANE D (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:D
Last Name:AVERY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:R
Other - Last Name:PORTWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3899
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79923-3899
Mailing Address - Country:US
Mailing Address - Phone:915-577-0030
Mailing Address - Fax:915-533-2568
Practice Address - Street 1:2415 E YANDELL DR
Practice Address - Street 2:STE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3616
Practice Address - Country:US
Practice Address - Phone:915-577-0030
Practice Address - Fax:915-533-2568
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX426206367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
22625OtherNURSE ANESTHETISTS
R57166Medicare UPIN
TX8A7949Medicare ID - Type Unspecified