Provider Demographics
NPI:1366561656
Name:RADVANSKY, DIANE E (CRNP)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:E
Last Name:RADVANSKY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1980 SUPPLEE RD
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5563
Mailing Address - Country:US
Mailing Address - Phone:215-456-7337
Mailing Address - Fax:215-456-7375
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-7337
Practice Address - Fax:215-456-7375
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP005392-B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP63391Medicare UPIN