Provider Demographics
NPI:1538157698
Name:RADER, DIANE L (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:RADER
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:PO BOX 100
Mailing Address - Street 2:82 PINE STREET
Mailing Address - City:FRANKLIN
Mailing Address - State:WV
Mailing Address - Zip Code:26807-0100
Mailing Address - Country:US
Mailing Address - Phone:304-358-2355
Mailing Address - Fax:304-212-7383
Practice Address - Street 1:15 MOTT STREET
Practice Address - Street 2:
Practice Address - City:HARMAN
Practice Address - State:WV
Practice Address - Zip Code:26270
Practice Address - Country:US
Practice Address - Phone:304-227-4134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV31793Medicaid
WVWV3179AMedicare PIN
S57325Medicare UPIN
WV3810004257Medicaid