Provider Demographics
NPI:1811988843
Name:PERINO, DIANE (PA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PERINO
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 268
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-0001
Mailing Address - Country:US
Mailing Address - Phone:617-696-4872
Mailing Address - Fax:617-696-9577
Practice Address - Street 1:100 HIGHLAND ST
Practice Address - Street 2:SUITE 123
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3881
Practice Address - Country:US
Practice Address - Phone:617-698-0099
Practice Address - Fax:617-698-4154
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA186363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS16465Medicare UPIN
MAAP0021Medicare ID - Type Unspecified