Provider Demographics
NPI:1710165790
Name:HOUSLEY, DIANA R
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:R
Last Name:HOUSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-6437
Mailing Address - Country:US
Mailing Address - Phone:520-586-3664
Mailing Address - Fax:520-586-3665
Practice Address - Street 1:890 W 4TH ST
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6437
Practice Address - Country:US
Practice Address - Phone:520-586-3664
Practice Address - Fax:520-586-3665
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2989363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109257Medicare PIN
AZQ13000Medicare UPIN