Provider Demographics
NPI:1306804653
Name:PACE, S DIANN (PA)
Entity type:Individual
Prefix:
First Name:S
Middle Name:DIANN
Last Name:PACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DIANN
Other - Middle Name:
Other - Last Name:PACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:124 FOY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2417
Mailing Address - Country:US
Mailing Address - Phone:252-937-2100
Mailing Address - Fax:252-937-7034
Practice Address - Street 1:124 FOY DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2417
Practice Address - Country:US
Practice Address - Phone:252-937-2100
Practice Address - Fax:252-937-7034
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2752127Medicare ID - Type Unspecified
S89651Medicare UPIN