Provider Demographics
NPI:1295791788
Name:KEISERMAN, DIANNA M (PA)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:M
Last Name:KEISERMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 N SENATE AVE
Mailing Address - Street 2:STE EF100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3763
Mailing Address - Country:US
Mailing Address - Phone:317-715-6402
Mailing Address - Fax:317-715-6415
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-278-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1433363A00000X
IN10001064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41963600Medicaid
WI41963600Medicaid
IN959090U4Medicare PIN