Provider Demographics
NPI:1982699070
Name:HENRY, DIANE M (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:HENRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1771 COUNTY ROAD 120 NE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-8009
Mailing Address - Country:US
Mailing Address - Phone:320-846-8171
Mailing Address - Fax:
Practice Address - Street 1:210 1ST ST N
Practice Address - Street 2:BOX 67
Practice Address - City:BERTHA
Practice Address - State:MN
Practice Address - Zip Code:56437-0067
Practice Address - Country:US
Practice Address - Phone:218-924-2250
Practice Address - Fax:218-924-2257
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9263363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP42106Medicare UPIN