Provider Demographics
NPI:1073895132
Name:DIEDRICK, RAINA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:RAINA
Middle Name:
Last Name:DIEDRICK
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 E OAKLAND PARK BLVD
Mailing Address - Street 2:STE 310
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1995 E OAKLAND PARK BLVD
Practice Address - Street 2:STE 310
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1138
Practice Address - Country:US
Practice Address - Phone:954-791-6146
Practice Address - Fax:954-337-2733
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000000000363A00000X
FLPA9107904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant