Provider Demographics
NPI:1851337109
Name:DIFANIS, MA R (NP)
Entity Type:Individual
Prefix:
First Name:MA
Middle Name:R
Last Name:DIFANIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:DIFANIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:602 W UNIVERSITY AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT NCW4
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2530
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-326-2856
Practice Address - Street 1:1701 CURTIS RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9678
Practice Address - Country:US
Practice Address - Phone:217-365-6203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004432363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3270617Medicare PIN
ILP78984Medicare UPIN