Provider Demographics
NPI:1285979138
Name:SEADERS, DIANA M (PA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:SEADERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 OAK ST SE STE 4030
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3984
Mailing Address - Country:US
Mailing Address - Phone:503-561-6444
Mailing Address - Fax:503-561-6440
Practice Address - Street 1:875 OAK ST SE STE 4030
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3984
Practice Address - Country:US
Practice Address - Phone:503-561-6444
Practice Address - Fax:503-561-6440
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5318363A00000X
ORPA164969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ767954Medicaid
AZZ92934Medicare PIN