Provider Demographics
NPI:1386723534
Name:PETROVICH, DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PETROVICH
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 1:1084 ROUTE 315
Mailing Address - Street 2:
Mailing Address - City:WILKES-BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-7012
Mailing Address - Country:US
Mailing Address - Phone:570-825-8741
Mailing Address - Fax:570-825-8990
Practice Address - Street 1:75 PINEAPPLE STREET
Practice Address - Street 2:BLACK CREEK HEALTH CENTER
Practice Address - City:NUREMBERG
Practice Address - State:PA
Practice Address - Zip Code:18241-0670
Practice Address - Country:US
Practice Address - Phone:570-384-3201
Practice Address - Fax:570-384-3454
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000042L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PE94891Medicare UPIN