Provider Demographics
NPI:1063552487
Name:BRUESSOW, DIANE M (PA-C)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:BRUESSOW
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 1:123 MAIN ST UNIT 60538
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-7026
Mailing Address - Country:US
Mailing Address - Phone:718-894-0301
Mailing Address - Fax:718-894-0301
Practice Address - Street 1:10 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MA
Practice Address - Zip Code:01062-3158
Practice Address - Country:US
Practice Address - Phone:718-894-0301
Practice Address - Fax:718-894-0301
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004819-1363A00000X
NJ25MP00141700363A00000X
WYPA1010363AM0700X
MAPA8022363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA8820OtherLICENSE
NY004819OtherLICENSE
NJ25MP00141700OtherLICENSE
CT6421OtherLICENSE
WYPA1010OtherLICENSE