Provider Demographics
NPI:1063561298
Name:AMIN, DIANE DRITT (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:DRITT
Last Name:AMIN
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 1:2427 STANWICK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-1544
Mailing Address - Country:US
Mailing Address - Phone:410-683-1719
Mailing Address - Fax:
Practice Address - Street 1:2427 STANWICK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-1544
Practice Address - Country:US
Practice Address - Phone:410-683-1719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD192528Y64Medicare PIN