Provider Demographics
NPI:1700599537
Name:CARRK, DIANE FAY (ACUPUNCTURIST)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:FAY
Last Name:CARRK
Suffix:
Gender:F
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 MAIN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12122-6519
Mailing Address - Country:US
Mailing Address - Phone:518-810-5224
Mailing Address - Fax:
Practice Address - Street 1:288 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURGH
Practice Address - State:NY
Practice Address - Zip Code:12122-6519
Practice Address - Country:US
Practice Address - Phone:518-810-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007223171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY843850215Medicaid