Provider Demographics
NPI:1710122767
Name:DOU, SI YAN DIANA (RPA-C)
Entity Type:Individual
Prefix:
First Name:SI YAN
Middle Name:DIANA
Last Name:DOU
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 PANDOLFI AVE
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-3136
Mailing Address - Country:US
Mailing Address - Phone:917-346-3298
Mailing Address - Fax:
Practice Address - Street 1:234 PANDOLFI AVE
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-3136
Practice Address - Country:US
Practice Address - Phone:917-346-3298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013054363AM0700X
NJ25MP001414400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical