Provider Demographics
NPI:1336233279
Name:DIAS, DIANE (PA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DIAS
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 1:16 ALEXANDER CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08882-1413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-1607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00143600363A00000X
NY012014-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ56315Medicare UPIN
NY5EE6GMW231Medicare PIN
NJ095858Medicare ID - Type Unspecified