Basic Information
| Provider Information | |||||||||
| NPI: | 1972660124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WETTERSTEN | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | 214 S. 4TH ST | ||||||||
| City: | KREMMLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804590399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707243442 | ||||||||
| FaxNumber: | 9707249606 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 SOUTH 4TH ST | ||||||||
| Address2: | BOX 399 | ||||||||
| City: | KREMMLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804590399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707243442 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 912 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 18388060 | 05 | CO | MEDICAID |