Provider Demographics
NPI:1992976047
Name:WISCHE, DIANA GAIL (CRNA)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:GAIL
Last Name:WISCHE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:G
Other - Last Name:KORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:100 ROUTE 59
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4927
Mailing Address - Country:US
Mailing Address - Phone:845-357-5775
Mailing Address - Fax:845-357-5777
Practice Address - Street 1:1 BAY AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4837
Practice Address - Country:US
Practice Address - Phone:973-429-6219
Practice Address - Fax:845-547-0740
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00226600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ020626T7YMedicare PIN