Provider Demographics
NPI:1962663609
Name:SMITH, DIANE MICHELLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MICHELLE
Last Name:SMITH
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 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8300
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:387 THEATRE RD
Practice Address - Street 2:
Practice Address - City:CARROLLTOWN
Practice Address - State:PA
Practice Address - Zip Code:15722-7805
Practice Address - Country:US
Practice Address - Phone:814-344-8477
Practice Address - Fax:814-344-2205
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053394363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA150751Medicare PIN