Provider Demographics
NPI:1558338822
Name:DIANA, MICHAEL RAYMOND (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:DIANA
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:7645 MERRILL RD STE 301
Practice Address - Street 2:UFJP MERRILL STATION FAMILY PRACTICE CENTER
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-6575
Practice Address - Country:US
Practice Address - Phone:904-699-0285
Practice Address - Fax:904-633-0286
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2011-06-22
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Provider Licenses
StateLicense IDTaxonomies
FLPA9101509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2910616-00Medicaid
FLP38396Medicare UPIN
FLE6066ZMedicare PIN
FL970021076Medicare PIN