Provider Demographics
NPI:1508319500
Name:DIEHL, DAVID RYAN
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RYAN
Last Name:DIEHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 KENDALL KNOLL WAY
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5963
Mailing Address - Country:US
Mailing Address - Phone:404-989-3425
Mailing Address - Fax:
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:SUITE 606
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:904-398-3356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10432367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant