Basic Information
| Provider Information | |||||||||
| NPI: | 1952563819 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLIDDEN | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | GAMEL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP, GNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3147 SW SAM JACKSON PARK RD | ||||||||
| Address2: | OHSU INTERNAL MEDICINE AND GERIATRICS CLINIC | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948562 | ||||||||
| FaxNumber: | 5034185505 | ||||||||
| Practice Location | |||||||||
| Address1: | 3147 SW SAM JACKSON PARK RD | ||||||||
| Address2: | OHSU INTERNAL MEDICINE AND GERIATRICS CLINIC | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948562 | ||||||||
| FaxNumber: | 5034185505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2008 | ||||||||
| LastUpdateDate: | 12/07/2015 | ||||||||
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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 | 363L00000X | 275124 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 201507841NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 0719251 | 05 | MA | MEDICAID |