MEDICARE: MISS DIANA LEE ANDERS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	WY445	WY
2	363A00000X	Physician Assistant	36138	MT
3	363A00000X	Physician Assistant	5595	OK
4	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1225292303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DIANA LEE ANDERS PA-C

Provider Business Mailing Address
First Line	:	PO BOX 776084
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-6084
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 WANDA ST
Second Line	:
City	:	MARIETTA
State	:	OK
Zip	:	73448-1200
Country	:	US
Telephone Number	:	580-276-3347
Fax Number	:	580-276-4795

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	01/09/2026

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