Provider Demographics
NPI:1447685276
Name:ALY, DIANE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:ALY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:DEMARTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:485 MONROE AVENUE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:07676
Mailing Address - Country:US
Mailing Address - Phone:201-388-7649
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:212-305-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant