Provider Demographics
NPI:1124076427
Name:DEWAN, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DEWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W 38TH ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1127
Mailing Address - Country:US
Mailing Address - Phone:512-454-9426
Mailing Address - Fax:512-454-7294
Practice Address - Street 1:900 W 38TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1127
Practice Address - Country:US
Practice Address - Phone:512-454-9426
Practice Address - Fax:512-454-7294
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01347363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q20946Medicare UPIN
8C1567Medicare ID - Type Unspecified