Basic Information
| Provider Information | |||||||||
| NPI: | 1558387449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIGGINS | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | LORY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 805 | ||||||||
| Address2: | |||||||||
| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959590805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302713232 | ||||||||
| FaxNumber: | 5302713239 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 ALDER AVE | ||||||||
| Address2: | SECOND FLOOR | ||||||||
| City: | INCLINE VILLAGE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894518335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758315308 | ||||||||
| FaxNumber: | 7758313295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 12/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A42102 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 10165 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A421021 | 05 | CA | MEDICAID | 100503371 | 05 | NV | MEDICAID | 10165 | 01 | NV STATE LICENSE | OTHER |