Provider Demographics
NPI:1205009735
Name:KOON, DIANA R (NP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:R
Last Name:KOON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 REPUBLIC PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6902
Mailing Address - Country:US
Mailing Address - Phone:972-620-9111
Mailing Address - Fax:972-620-9187
Practice Address - Street 1:1675 REPUBLIC PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6902
Practice Address - Country:US
Practice Address - Phone:972-620-9111
Practice Address - Fax:972-620-9187
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX563192363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151079402Medicaid
TX151079403Medicaid
TX151079404Medicaid
TX151079403Medicaid
TXTXB121401Medicare PIN
TXTXB121654Medicare PIN
TX151079402Medicaid
TX8L18633Medicare PIN
TX8L18646Medicare PIN
TX8K7580Medicare PIN