Provider Demographics
NPI:1821147208
Name:BROWN, DIANE (PA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
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Other - Middle Name:
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Mailing Address - Street 1:506 WEST GRAHAN AVENUE SUITE 107
Mailing Address - Street 2:OLIVEIRA MEDICAL INC.
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530
Mailing Address - Country:US
Mailing Address - Phone:951-471-5116
Mailing Address - Fax:951-471-5226
Practice Address - Street 1:506 WEST GRAHAN AVENUE SUITE 107
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530
Practice Address - Country:US
Practice Address - Phone:951-471-5116
Practice Address - Fax:951-471-5226
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-11-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA14724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S70360Medicare UPIN