Provider Demographics
NPI:1285731711
Name:WILSON, DIANE ORSAK (CNP CNS)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ORSAK
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNP CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 DESERT LAKES RD
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-7757
Mailing Address - Country:US
Mailing Address - Phone:575-430-9375
Mailing Address - Fax:
Practice Address - Street 1:508 DESERT LAKES RD.
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310
Practice Address - Country:US
Practice Address - Phone:575-430-9375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01596363LA2200X
NMR45375364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34751777Medicaid
347300704Medicare ID - Type Unspecified
P73133Medicare UPIN