Provider Demographics
NPI:1700873700
Name:WARMOTH, DIANE L (PA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:WARMOTH
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 UNIVERSITY BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665
Practice Address - Country:US
Practice Address - Phone:512-509-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX062599802Medicaid
TX337171802Medicaid
TX337171803Medicaid
TXP00368045Medicare PIN
TX337171802Medicaid
TX337171803Medicaid