Provider Demographics
NPI:1134681562
Name:ACOSTA, DIANA MARIA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIA
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3347 S STATE ROAD 7 STE 203
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8148
Mailing Address - Country:US
Mailing Address - Phone:561-793-6100
Mailing Address - Fax:
Practice Address - Street 1:3347 S STATE ROAD 7 STE 203
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8148
Practice Address - Country:US
Practice Address - Phone:561-793-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113517363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty