Provider Demographics
NPI:1740824630
Name:ANDERSON, DIANA (PA-C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:920 STANTON L YOUNG BLVD STE 2040
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5036
Mailing Address - Country:US
Mailing Address - Phone:405-271-4113
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD STE 2040
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-4113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA3111363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical