Provider Demographics
NPI:1841881596
Name:SRADER, DIANE GAIL
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:GAIL
Last Name:SRADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 S US HIGHWAY 75 STE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4587
Mailing Address - Country:US
Mailing Address - Phone:806-351-7530
Mailing Address - Fax:806-351-7539
Practice Address - Street 1:1900 SE 34TH AVE UNIT 1700
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79118-6732
Practice Address - Country:US
Practice Address - Phone:806-351-7530
Practice Address - Fax:806-351-7539
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143946363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1O0144OtherPTAN