Provider Demographics
NPI:1205940962
Name:NIELSEN, DIANE RAE (PA C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:RAE
Last Name:NIELSEN
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 1:3430 WASHINGTON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-523-3060
Mailing Address - Fax:208-523-0028
Practice Address - Street 1:3430 WASHINGTON PARKWAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-523-3060
Practice Address - Fax:208-523-0028
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA178208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAKY2OtherBLUE CROSS
ID004378700Medicaid
ID000010016257OtherBLUE SHIELD