Provider Demographics
NPI:1750690392
Name:AFONSO, DIANA M (PA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:AFONSO
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 1:375 ALLENS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5010
Mailing Address - Country:US
Mailing Address - Phone:401-444-0400
Mailing Address - Fax:
Practice Address - Street 1:355 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-1928
Practice Address - Country:US
Practice Address - Phone:401-415-9000
Practice Address - Fax:401-396-2065
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00561363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI111010OtherBCBSRI
RI939025129OtherRI MEDICARE GROUP
RI0018646OtherRI MEDICARE
RI10-01-2010OtherUNITED HEALTHCARE
RI11-11-2010OtherNHPRI
RIDA82553Medicaid