Provider Demographics
NPI:1881916401
Name:WRIGHT, DIANA L (PA-C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S NEVADA AVENUE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401
Mailing Address - Country:US
Mailing Address - Phone:970-249-7751
Mailing Address - Fax:970-249-5029
Practice Address - Street 1:456 KOKOPELLI BLVD, SUITE B
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521
Practice Address - Country:US
Practice Address - Phone:970-639-9505
Practice Address - Fax:970-639-2993
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60371999363A00000X
COPA.0002968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78357250Medicaid
CO542099YYS0OtherMEDICARE FOR CEDAR POINT HEALTH