Provider Demographics
NPI:1972660124
Name:WETTERSTEN, DIANNE L (PA)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:L
Last Name:WETTERSTEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:214 S. 4TH ST
Mailing Address - City:KREMMLING
Mailing Address - State:CO
Mailing Address - Zip Code:80459-0399
Mailing Address - Country:US
Mailing Address - Phone:970-724-3442
Mailing Address - Fax:970-724-9606
Practice Address - Street 1:214 SOUTH 4TH ST
Practice Address - Street 2:BOX 399
Practice Address - City:KREMMLING
Practice Address - State:CO
Practice Address - Zip Code:80459-0399
Practice Address - Country:US
Practice Address - Phone:970-724-3442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18388060Medicaid
CO18388060Medicaid