Basic Information
Provider Information
NPI: 1003802752
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: YASTRUB
FirstName: DIANE
MiddleName: J
NamePrefix: MS.
NameSuffix:  
Credential: FNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 9937 E HIDDEN TREASURE CT
Address2:  
City: GOLD CANYON
State: AZ
PostalCode: 851185876
CountryCode: US
TelephoneNumber: 5163135563
FaxNumber:  
Practice Location
Address1: 9937 E HIDDEN TREASURE CT
Address2:  
City: GOLD CANYON
State: AZ
PostalCode: 851185876
CountryCode: US
TelephoneNumber: 5163135563
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/27/2005
LastUpdateDate: 04/08/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 04/08/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X235723AZY193400000X SINGLE SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
363LF0000XF332974-1NYN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

ID Information
IDTypeStateIssuerDescription
0207764505NY MEDICAID
P237417201NYOXFORD PROVIDER NUMBEROTHER


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