Provider Demographics
NPI:1104997519
Name:SCANZAROLI, DIANE M (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:SCANZAROLI
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 1:1532 GALENA ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80010-2287
Mailing Address - Country:US
Mailing Address - Phone:303-900-8639
Mailing Address - Fax:720-204-5534
Practice Address - Street 1:1532 GALENA ST
Practice Address - Street 2:SUITE 300
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-2287
Practice Address - Country:US
Practice Address - Phone:303-900-8639
Practice Address - Fax:720-204-5534
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44008392Medicaid
Q04615Medicare UPIN
105386Medicare ID - Type Unspecified
AZ835621-03Medicaid