Provider Demographics
NPI:1366042574
Name:DISKIN, ERIN DOMINIQUE (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:DOMINIQUE
Last Name:DISKIN
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 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:460 N ORLANDO AVE
Practice Address - Street 2:STE 200 BLDG D
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2988
Practice Address - Country:US
Practice Address - Phone:407-898-5452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113511363A00000X
FLPAX9113511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110720100Medicaid