Healthcare Provider Details

I. General information

NPI: 1750326674
Provider Name (Legal Business Name): RICHARD ROBERT DIANA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL ROAD MEDICAL CENTER
PATCHOGUE NY
11772
US

IV. Provider business mailing address

PO BOX 13700-1378 BROOKHAVEN MEMORIAL HOSPITAL ER
PHILADELPHIA PA
19191-1378
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-2953
  • Fax: 610-617-6280
Mailing address:
  • Phone: 800-666-2455
  • Fax: 610-617-6280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number044920
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: