Provider Demographics
NPI:1821105164
Name:DIACONOU, JOHN N (MD PS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:N
Last Name:DIACONOU
Suffix:
Gender:M
Credentials:MD PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N DIVISION ST
Mailing Address - Street 2:STE 402
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-4939
Mailing Address - Country:US
Mailing Address - Phone:253-833-8032
Mailing Address - Fax:253-833-8081
Practice Address - Street 1:202 N DIVISION ST
Practice Address - Street 2:STE 402
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-4939
Practice Address - Country:US
Practice Address - Phone:253-833-8032
Practice Address - Fax:253-833-8081
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000187422086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACH9408OtherRR MEDICARE GROUP #
WA1779008Medicaid
WA230000055OtherRAILROAD MEDICARE PIN
WA0265721OtherSTATE L&I
WA0152713OtherLABOR AND INDUSTRIES
WA0244706OtherSTATE L&I
G8874750Medicare PIN
WACH9408OtherRR MEDICARE GROUP #
WA230000055OtherRAILROAD MEDICARE PIN
WA0152713OtherLABOR AND INDUSTRIES