Provider Demographics
NPI:1295277598
Name:LU, DIANE (MMS, PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LU
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 ELM ST UNIT 910
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-2534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:198 MASSACHUSETTS AVE STE 103
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-4143
Practice Address - Country:US
Practice Address - Phone:978-685-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020338363AS0400X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical