Provider Demographics
NPI:1124320874
Name:DEMOPULOS, DIANE KAY (ARNP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:KAY
Last Name:DEMOPULOS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 116TH AVE NE
Mailing Address - Street 2:SUITE D1
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3058
Mailing Address - Country:US
Mailing Address - Phone:425-455-2131
Mailing Address - Fax:
Practice Address - Street 1:1810 116TH AVE NE
Practice Address - Street 2:SUITE D1
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3058
Practice Address - Country:US
Practice Address - Phone:425-455-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002359363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9606245Medicaid
WAP71811Medicare UPIN