Provider Demographics
NPI:1023034592
Name:DIAMOND, SUSAN LEIGH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LEIGH
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0001
Mailing Address - Country:US
Mailing Address - Phone:904-390-3610
Mailing Address - Fax:904-288-5890
Practice Address - Street 1:5153 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8785
Practice Address - Country:US
Practice Address - Phone:850-505-4700
Practice Address - Fax:850-505-4711
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009934557Medicaid
FL292371800Medicaid
MS00754233Medicaid
KY7100021450Medicaid
MS00754233Medicaid
U6646AMedicare PIN