Provider Demographics
NPI:1366594962
Name:DEWOLFE, DIANA (PA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DEWOLFE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 N GEORGE MASON DR
Mailing Address - Street 2:STE 150
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3679
Mailing Address - Country:US
Mailing Address - Phone:301-663-6162
Mailing Address - Fax:301-694-8525
Practice Address - Street 1:1635 N. GEORGE MASON DRIVE
Practice Address - Street 2:SUITE 150
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205
Practice Address - Country:US
Practice Address - Phone:301-663-6162
Practice Address - Fax:301-694-8525
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002675363A00000X
MDC0003209363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPA60189OtherCDS
MDPA60189OtherCDS