Provider Demographics
NPI:1972660124
Name:WETTERSTEN, DIANNE LYNNE (PAC)
Entity type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:LYNNE
Last Name:WETTERSTEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 OLD DEER PATH WAY
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-4245
Mailing Address - Country:US
Mailing Address - Phone:970-531-6736
Mailing Address - Fax:
Practice Address - Street 1:700 CHIEF EDDIE HOFFMAN HWY YUKON-KUSKOKWIN HEALTH CORP
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK230955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18388060Medicaid
CO18388060Medicaid