Provider Demographics
NPI:1891036059
Name:ROETTING, DIANA TONG (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:TONG
Last Name:ROETTING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2952 CRAFTSMAN LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-4392
Mailing Address - Country:US
Mailing Address - Phone:512-296-9112
Mailing Address - Fax:
Practice Address - Street 1:130 PROVIDENCE RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1242
Practice Address - Country:US
Practice Address - Phone:704-333-9113
Practice Address - Fax:704-333-9757
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04133363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01191996Medicare PIN