Provider Demographics
NPI:1497975130
Name:DIFO, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DIFO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 UNIVERSITY SQUARE DR
Mailing Address - Street 2:RADIOLOGY ASSOC OF TAMPA
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5513
Mailing Address - Country:US
Mailing Address - Phone:813-251-5822
Mailing Address - Fax:
Practice Address - Street 1:1 TAMPA GENERAL CIR
Practice Address - Street 2:TGH INTERVENTIONAL RADIOLOGY
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-844-4570
Practice Address - Fax:813-844-4032
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY00S4OtherBLUE CROSS BLUE SHIELD
FL292737300Medicaid
FLAG340ZMedicare PIN
FLAG340XMedicare PIN
FLY00S4OtherBLUE CROSS BLUE SHIELD
FLP00887969Medicare PIN