Provider Demographics
NPI:1518990928
Name:DREVS, DIANE M (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:DREVS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:814 PIERCE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1058
Mailing Address - Country:US
Mailing Address - Phone:712-226-2600
Mailing Address - Fax:712-226-2605
Practice Address - Street 1:3250 PLAZA DR
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3144
Practice Address - Country:US
Practice Address - Phone:402-412-4220
Practice Address - Fax:402-494-1365
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE696363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13646OtherWELLMARK
IA13646OtherWELLMARK
IAI16175Medicare ID - Type Unspecified
NE279476Medicare ID - Type Unspecified