Basic Information
| Provider Information | |||||||||
| NPI: | 1003802752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YASTRUB | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F332974-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 235723 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02077645 | 05 | NY | MEDICAID | P2374172 | 01 | NY | OXFORD PROVIDER NUMBER | OTHER |