Provider Demographics
NPI:1952563819
Name:GLIDDEN, DIANA GAMEL (ANP, GNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:GAMEL
Last Name:GLIDDEN
Suffix:
Gender:F
Credentials:ANP, GNP
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3147 SW SAM JACKSON PARK RD
Mailing Address - Street 2:OHSU INTERNAL MEDICINE AND GERIATRICS CLINIC
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-8562
Mailing Address - Fax:503-418-5505
Practice Address - Street 1:3147 SW SAM JACKSON PARK RD
Practice Address - Street 2:OHSU INTERNAL MEDICINE AND GERIATRICS CLINIC
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8562
Practice Address - Fax:503-418-5505
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA275124363L00000X
OR201507841NP-PP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0719251Medicaid