Individual
MS. DIANE M BRUESSOW
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
10 MAIN ST STE 3, FLORENCE, MA 01062-3158
(718) 894-0301
(718) 894-0301
Mailing address
123 MAIN ST UNIT 60538, FLORENCE, MA 01062-7026
(718) 894-0301
(718) 894-0301
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
004819-1
NY
363A00000X
Physician Assistant
25MP00141700
NJ
363AM0700X
Medical Physician Assistant
PA1010
WY
363AM0700X
Medical Physician Assistant
Primary
PA8022
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
004819
LICENSE
NY
01
—
25MP00141700
LICENSE
NJ
01
—
6421
LICENSE
CT
01
—
PA1010
LICENSE
WY
01
—
PA8820
LICENSE
MA
Enumeration date
02/07/2007
Last updated
02/03/2025
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