Provider Demographics
NPI:1972653160
Name:MARL, DIANA K (PA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:K
Last Name:MARL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:K
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 4059
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4059
Mailing Address - Country:US
Mailing Address - Phone:973-826-8291
Mailing Address - Fax:855-834-5436
Practice Address - Street 1:4215 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-2206
Practice Address - Country:US
Practice Address - Phone:407-539-2000
Practice Address - Fax:407-398-0050
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105415363AS0400X, 363A00000X
WV00517363A00000X
OH50000868363A00000X, 363AS0400X
WV517363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHF826AOtherMEDICARE GRP PTAN
FLDZ490ZMedicare PIN
S96390Medicare UPIN
OHPA14762Medicare ID - Type Unspecified
WVPA14763Medicare ID - Type Unspecified
FLHF826AOtherMEDICARE GRP PTAN