Provider Demographics
NPI:1023531167
Name:ELKASSIS, DIANA (PA-C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:ELKASSIS
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 1:5514 MEADOWCREST DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4041
Mailing Address - Country:US
Mailing Address - Phone:810-813-5566
Mailing Address - Fax:
Practice Address - Street 1:5514 MEADOWCREST DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4041
Practice Address - Country:US
Practice Address - Phone:810-813-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2023-06-07
Deactivation Date:2020-03-31
Deactivation Code:
Reactivation Date:2020-04-09
Provider Licenses
StateLicense IDTaxonomies
MI5601010054363A00000X
NY029645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant