Provider Demographics
NPI:1083609002
Name:MCAVOY, DIANE CAROL (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:CAROL
Last Name:MCAVOY
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 1:220 TILGHMAN RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-1921
Mailing Address - Country:US
Mailing Address - Phone:570-592-5607
Mailing Address - Fax:
Practice Address - Street 1:220 TILGHMAN RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-1921
Practice Address - Country:US
Practice Address - Phone:410-219-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009493363A00000X
PAMA001866L363A00000X
IL085.009493363AM0700X
MDC0007548363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035418490002Medicaid
PAP22259Medicare UPIN