Provider Demographics
NPI:1205959954
Name:WYSOCK, DIANE BIGGERS (CRNA)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:BIGGERS
Last Name:WYSOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:BIGGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 650782
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0782
Mailing Address - Country:US
Mailing Address - Phone:302-733-0705
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:701 N CLAYTON ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3158
Practice Address - Country:US
Practice Address - Phone:302-421-4330
Practice Address - Fax:302-421-4331
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0021722163W00000X
DEL6-0A00534367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE077581OtherAANA ID#
DEP00728377OtherRAILROAD MEDICARE
DE130662Medicare PIN