Provider Demographics
NPI:1659367407
Name:WALTER, DIANA HERTEL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:HERTEL
Last Name:WALTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:HERTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:455 PINELLAS ST STE 320
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3369
Mailing Address - Country:US
Mailing Address - Phone:727-446-2273
Mailing Address - Fax:727-447-5972
Practice Address - Street 1:455 PINELLAS ST STE 320
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3369
Practice Address - Country:US
Practice Address - Phone:727-446-2273
Practice Address - Fax:727-441-4966
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102544363A00000X
FLPA102544363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105528400Medicaid
FLU1771XMedicare PIN