Basic Information
Provider Information | |||||||||
NPI: | 1851555163 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BISHOP | ||||||||
FirstName: | DIANNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DSC, CERT MDT, C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REINSEL | ||||||||
OtherFirstName: | DIANNA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 350 NEW FIDELITY CT | ||||||||
Address2: |   | ||||||||
City: | GARNER | ||||||||
State: | NC | ||||||||
PostalCode: | 275292665 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193732919 | ||||||||
FaxNumber: | 4106484878 | ||||||||
Practice Location | |||||||||
Address1: | 2007 MEADE PKWY | ||||||||
Address2: |   | ||||||||
City: | SUFFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 234344259 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7575396300 | ||||||||
FaxNumber: | 7575390704 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2008 | ||||||||
LastUpdateDate: | 08/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305002030 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1851555163 | 01 | VA | MEDICAID QMB | OTHER | 004979796 | 05 | VA |   | MEDICAID | C05954 | 01 | VA | MEDICARE GROUP NUMBER | OTHER |